Pulmonology Coding Alert

Question: If a pulmonologist provides a patient in the hospital with critical care for 45 minutes, and on the same day another pulmonologist from the same group provides additional critical care to the same patient, how should I code the second provider's services 99291 or 99292? Are we entitled to bill 99291 twice if the cumulative time only adds up to 74 minutes?

Arizona Subscriber

Answer: Critical care is a time-based service. Multiple physicians from the same practice may report 99291 and 99292 if the cumulative critical care time adds up to 75-104 minutes. But you should tie the billing to one physician in the group, usually the doctor who provided the initial 99291 service.

This concept does not apply to the scenario presented in the question. The first pulmonologist provided 45 minutes of critical care, and even though the second physician provided additional critical care, the total amount of critical care time for both physicians was 74 minutes. Consequently, only the physician providing 45 minutes of critical care can report such services.

The second pulmonologist could have provided only 29 minutes of critical care. He or she did not meet the time requirement for critical care (99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes). In this scenario, you should report only 99291, and this code may be reported only once for that date of service.

You can capture the other physician's 29 minutes of service only if he or she evaluated the patient before any critical care was provided. For example, physician A reported an inpatient E/M service code (e.g., 99233, Subsequent hospital care, per day, for the evaluation and management of a patient ), and later in the day, there was a change or deterioration in the patient's condition necessitating critical care, and physician B provided these services.

Critical care documentation should include the change in the patient's condition, the service(s) provided, and the duration of the critical care. When reporting these two separate E/M services (critical care and inpatient E/M), you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the inpatient E/M service.

Of course, you should remember that non-Medicare carriers may choose to pay for only one service from the same group on the same day.