Pulmonology Coding Alert

The OIG has added this issue to its current Work Plan.

You’ve heard about private payers and MACs that scrutinize critical care claims, but this time you may be in for a bigger surprise: The OIG has turned its sights to these services, and will launch nationwide reviews of these claims.

In early August 2018, CMS added a new topic to its Work Plan, entitled “Physicians Billing for Critical Care Evaluation and Management Services.” According to Medicare data, pulmonologists come in only behind internal medicine physicians as the specialists who report the most critical care codes to MACs.

In reviewing Medicare’s code utilization data from 2017, critical care code 99291 is the sixth-most-billed code by pulmonologists, reported more often than E/M codes 99212 or 99203, and solidifying the reality that pulmonologists frequently see very sick patients.

Know What the OIG Is Seeking

The new Work Plan item notes the following about critical care services and what the audit focus will be (emphasis is added by Pulmonology Coding Alert):

“Critical care is defined as the direct delivery of medical care by a physician(s) for a critically ill or critically injured patient. Critical care is usually given in a critical care area such as a coronary, respiratory, or intensive care unit, or the emergency department. Payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care. Critical care is exclusively a time-based code. Medicare pays physicians based on the number of minutes they spend with critical care patients. The physician must spend this time evaluating, providing care and managing the patient’s care and must be immediately available to the patient. This review will determine whether Medicare payments for critical care are appropriate and paid in accordance with Medicare requirements.”

Pulmonology Coding Alert is breaking down the bolded provisions in the OIG’s statement above so you can ensure that you’re meeting the elements that auditors are about to start reviewing. If your records are audited, you’ll be better prepared for the review by getting to know these facts.

1. Critically Ill or Injured Patient

Whether the patient was critically ill or injured is perhaps the most important question you’ll need to answer on any critical care claim. You must be able to establish that the patient is critically ill or injured to report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) or +99292 (...  each additional 30 minutes [List separately in addition to code for primary service]).

CPT^®’s definition states, “A critical illness or injury acutely impairs one or more vital organ systems such that there is high probability of imminent or life-threatening deterioration in the patient’s condition.”

The imminent threat of permanent harm can be to life or organ system, such as circulatory failure or respiratory failure. In addition, minimal time thresholds of care, at least 30 minutes, must be clear from the medical records. It is also important to note that the provider who is reporting critical care time should be taking care of the issue that qualifies as the critical illness or injury, and not addressing a separate, non-critical issue.

2. Payment May Be Made for Critical Care Services Provided in Any Location

The place of service for critical care when reporting 99291-+99292 is not restricted in CPT^® or based on CMS rules, other than to identify typical areas of a facility where it may occur. While most critical care will occur in a critical care area (ICU, ED, etc.), the physician can bill 99291 for services performed in any place of service the patient requiring it presents. The one site that is not allowable for critical care is an ambulance, unless the physician is treating a pediatric patient.

Providing critical care services is based on the patient’s condition and the acuity of the service being provided. A patient being monitored in an intensive care unit but whose organ systems are in stable condition may not meet the criteria for critical care services. In contrast, a patient in respiratory failure may require critical care services even though the patient has not yet been admitted to the hospital.

3. Exclusively A Time-Based Code

The duration of critical care services for both CPT^® and Medicare is based on the physician’s documentation of total time spent evaluating, managing, and providing care to the critical patient, as well as time spent in documenting such activities. The physician must devote full attention to the particular patient for every minute of time claimed.

The critical care codes 99291 and +99292 are used to report the total duration of time spent by a physician providing critical care services, even if the time spent by the physician on that date is not continuous. You can aggregate non-continuous time for critical care services for a single date. Use CPT^® code 99291 to report the first 30-74 minutes of critical care on a given date, but only report it once per date. Use code +99292 to report additional block(s) of time of up to 30 minutes each beyond the first 74 minutesof critical care.

Don’t use the critical care codes to report critical care time of less than 30 minutes. Instead, report such service the appropriate E/M code, likely 99285 based on the nature of the presenting problem documented.

The CPT^® book introduction discusses time threshold requirements for code sets that contain a time basis for code selection. “The following standards shall apply to time measurement, unless there are code or code-range-specific instructions in guidelines, parenthetical instructions, or code descriptors to the contrary. A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes). A second hour is attained when a total of 91 minutes have elapsed,” the manual advises.

In the case of code 99291, there is specific language in CPT^® that states 30 minutes both in the code descriptor itself and in the time threshold chart in the critical care section preamble. So for 99291, CPT^® describes a threshold of at least 30 minutes, when the midpoint would have been passed.

4. Spend Time Evaluating, Providing Care, and Managing the Patient’s Care

The physician can spend the time at the patient’s bedside, reviewing test results, discussing the case with staff, documenting the medical record, and discussing the patient’s condition with family members (or surrogate decision makers) discussing specific treatment issues when the patient is unable or clinically incompetent to participate in providing history or making management decisions.

Take note: When the provider performs separately reportable procedures or services, you cannot count that time as part of the total time you report as critical care time. You also can’t count time involved in activities like restocking of supplies that do not directly contribute to the treatment of the critical patient toward the critical care time.

5. Immediately Available to the Patient

If you’re counting time toward critical care, you must be immediately available to the patient. If the physician leaves the building, goes to lunch, or ends his shift and leaves, you cannot count that time toward the critical care tally.