Wiki Critical Care 99291

[cwrigh1@gmail.com]

I'm looking for some help! One of my providers says he found on CMS that "one provider can only bill 12 critical care visits per day". Has anyone come across this? I can't find it. Thank you for your help.

 

[cgaston]

I think he misread "12 hours". Per the attached:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

This is found on page 69:

For Medicare Part B physician services paid under the physician fee schedule, critical
care is not a service that is paid on a “shift” basis or a “per day” basis. Documentation
may be requested for any claim to determine medical necessity. Examples of critical care
billing that may require further review could include: claims from several physicians
submitting multiple units of critical care for a single patient, and submitting claims for
more than 12 hours of critical care time by a physician for one or more patients on the
same given calendar date. Physicians assigned to a critical care unit (e.g., hospitalist,
intensivist, etc.) may not report critical care for patients based on a ‘per shift” basis.
The CPT code 99291 is used to report the first 30 - 74 minutes of critical care on a given
calendar date of service. It should only be used once per calendar date per patient by the
same physician or physician group of the same specialty. CPT code 99292 is used to
report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of
critical care (See table below). Critical care of less than 30 minutes total duration on a
given calendar date is not reported separately using the critical care codes. This service
should be reported using another appropriate E/M code such as subsequent hospital care.

 

[cwrigh1@gmail.com]

Thank you so much for your help! I will send this information to my Practice Manager.