Medicare Compliance & Reimbursement

Question: Recently, our facility admitted an established heart patient with acute respiratory failure. The patient was attended to by two physicians during the stay, a pulmonologist and cardiologist, in critical care settings. Can both the physicians bill for critical care separately? On the second day, due to the unavailability of the attending pulmonologist, another physician of the same specialty attended to the patient. Can he bill separately for the visit?

Answer: For your first question, yes. More than one physician can provide critical care on the same day and be paid, provided that the following conditions are met:

• the service meets critical care,
• the service is medically necessary,
• the service is not duplicative care,
• both physicians are not providing the care during the same minutes of the day.

Concurrent care by more than one physician (generally representing different physician specialties) is payable if these requirements are met (refer to the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, §30 forconcurrent care policy discussion).

The CPT® critical care codes 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]) are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous. Non-continuous time for medically necessary critical care services may be aggregated. Reporting CPT® code 99291 is a prerequisite to reporting CPT® code 99292.

For your second question, physicians of the same specialty within the same group practice bill and are paid as though they were a single physician (§30.6.5).If the covering pulmonologist was the only one from the group to see the patient on that day, then he/she will bill the service under his/her name. If the initial pulmonologist sees the patient earlier that day, and the patient requires a second visit by the group member, then all time is counted together and reported under one physician.