Urology Coding Alert

MPFS Final Rule:

Know Your Payer Before Reporting +99292

Published on Wed Feb 15, 2023

CMS changes its tune on how you’ll count critical care time.

If you focused your review of the 2023 Medicare Physician Fee Schedule (MPFS) final rule on the conversion factor adjustment, you may have missed an important update about critical care coding.

The lowdown: The Centers for Medicare & Medicaid Services (CMS) tucked a technical correction into this year’s final rule, clearing up a lack of clarity and consistency regarding CMS policy on when you can report critical care add-on code +99292 (Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service).

The only problem is that the correction firmly puts Medicare payers and CPT^®at opposite ends of the spectrum when it comes to coding +99292. Read on for more information on this potentially confusing issue.

CMS: No +99292 Until 104 Minutes

In both the 2023 proposed and final rules, CMS issued a “Technical Correction for Split (or Shared) Critical Care Services.”

The correction states:

“In the CY 2022 PFS final rule … we finalized a number of billing policies for critical care CPT 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). … We stated in error, ‘Similar to our proposal for split (or shared) prolonged visits, the billing practitioner would first report CPT code 99291 and, if 75 or more cumulative total minutes were spent providing critical care, the billing practitioner could report one or more units of CPT code 99292.’”

The original statement in the 2022 final rule put CMS and CPT^®guidelines firmly on the same page, as both governing bodies called for a unit of +99292 to be reported after a critical care session reached the 75-minute threshold.

Then, the MPFS 2023 proposed rule came out in July 2022 and the final rule in December 2022, in which CMS reversed course. Per the final rule:

“We intended to state that CPT code 99292 could be billed after 104, not 75, or more cumulative total minutes were spent providing critical care. … 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. CPT code 99292 is reportable for additional, complete 30-minute time increments furnished to the same patient (74 + 30 = 104 minutes).”

Critical Care Claims Now More Payer-Specific

This makes coding for critical care more confusing and will put the onus on coders when deciding whether to report +99292, says Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Michigan.

From now on, coders will need to ask “Where does time start?” for each +99292-eligible critical care encounter. “If you look at the CPT^®codes, it’s 99291 for the first 30 to 74 minutes. At 75 minutes, you would report +99292 — but not for CMS,” Young says. When you’re reporting by the Medicare rules, you need 104 minutes to fulfill the full 30 minutes of the add-on code to report it. You can find a table outlining the AMA CPT^®time guidelines in the critical care guidelines that appear just before 99291 in the 2023 AMA CPT^® code book.

So if you are considering +99292 there are miscoding risks that will come with the claim. Young recommends giving coders more power in order to streamline the critical care coding process and stay compliant. “Physicians need to give the [critical care] times to their billers and let the billers apply the rules,” Young explains.

This difference has the potential to be a big issue, especially on longer critical care claims. As Young states, “105 minutes to one payer is +99292 and +99292 x 2 to another payer. This has the potential to be an entire +99292 payment.”