Medicare Compliance & Reimbursement

If you’re still sifting through changes announced in the CY Medicare Physician Fee Schedule (MPFS) final rule, you’re not alone. The rule issued an important clarification on billing for critical care codes — but some critical care basics didn’t change and that’s caused some confusion.

Update: While most hospital/inpatient evaluation and management (E/M) services received revised descriptors in 2023, critical care stood fast. The definitions for 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (… each additional 30 minutes (List separately in addition to code for primary service)) remain unchanged in 2023.

That’s not to say that coding for critical care isn’t challenging. Read on for more information on the basics of reporting 99291/+99292.

Know Critical Illness/Injury Definition

The first thing to know about critical care coding: The patient must be critically ill or injured in order to report 99291/+99292.

“CPT^® states that a critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition,” explains Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Michigan.

The physician will be the one deciding whether or not the patient is critically ill or injured; coders, however, can be on the lookout for potential critical care in certain situations.

According to Young, examples of potential critical care scenarios include:

• Patient with atrial fibrillation (heart in irregular rhythm posing threat to life);
• Patient involved in motorcycle accident who comes into ED with multiple injuries (fractures, injured organs, etc.); or
• Physician stays with patient to stabilize function while specialists address fractures, contusions, abrasions, etc.

Sharon Richardson, RN, offers up these examples of presentations that could end up in critical care treatment:

Patient in respiratory distress, tripoding, using accessory muscles to breath, and requiring aggressive management by the physician in order to prevent intubation. Management could include multiple or extensive breathing treatments, bilateral positive airway pressure (BiPap), steroids, epinephrine, etc.

• Patient has uncontrolled atrial fibrillation (A-Fib) with hypotension, dyspnea, and possibly chest pain.
• Physician provides treatment with an antiarrhythmic, possibly a drip with or without conversion/cardioversion.
• Physician provides aggressive management of chest pain, with multiple doses of nitrogen/nitrogen drip.

Remember to Include These Services in Critical Care

There are a lot of services that could occur while your physician provides critical care. Many of these services are bundled into the critical care codes, and you should never code for them and 99291/+99292 for the same patient encounter.

CPT^® lists the following services as bundled into 99291/+99292:

• Interpretation of cardiac output measurements (+93598)
• Chest X-rays (71045, 71046)
• Pulse oximetry (94760, 94761, 94762)
• Blood gases, and collection and interpretation of physiologic data (eg. ECGs, blood pressures, hematologic data)
• Gastric intubation (43752, 43753)
• Temporary transcutaneous pacing (92953)
• Ventilatory management (94002-94004, 94660, 94662
• Vascular access procedures (36000, 36410, 36415, 36591, 36600)

“Any services performed that are not included in this listing should be reported separately,” according to CPT^®.

Count Non-Continuous Critical Care Minutes

Coders need to remember that critical care time does not need to be continuous; for example, the physician could provide 55 minutes of critical care for a patient in the morning, then 23 more in the afternoon. If coders miss the afternoon minutes, they’ll only be able to report 99291. If, however, the coder captures both instances of critical care and adds them up, they might be able to report 99291 and +99292 (for payers that follow CPT^® rules).

Reminder: Beginning in 2023, the Centers for Medicare & Medicaid Services (CMS) is not in alignment with CPT^® on the time thresholds required for reporting the add-on code +99292 to the first 74 minutes of critical care represented by 99291. CMS insists on a 30-minute buffer before applying +99292, according to the CY 2023 MPFS final rule, published in the Federal Register last November.

“As correctly stated elsewhere in the CY 2022 PFS final rule (regarding critical care furnished by single physicians at 86 FR 65160, and regarding concurrent care furnished by multiple practitioners in the same group and the same specialty to the same patient at 86 FR 65162), our policy is that CPT^® code 99291 is reportable for the first 30-74 minutes of critical care services furnished to a patient on a given date,” CMS says. “CPT^® code +99292 is reportable for additional, complete 30-minute time increments furnished to the same patient (74 + 30 = 104 minutes).”

The agency adds, “We clarify that our policy is the same for critical care whether the patient is receiving care from one physician, multiple practitioners in the same group and specialty who are providing concurrent care, or physicians and NPPs who are billing critical care as a split (or shared) visit.”

Resource: Review the CY 2023 MPFS at www.govinfo.gov/ content/pkg/FR-2022-11-18/pdf/2022-23873.pdf.