Concurrent Care
Critically ill patients often require the care of hospitalists and other specialists throughout the course of treatment. Payors are sensitive to the multiple hours billed by multiple providers for a single patient on a given day. Claim logic provides an automated response to only allow reimbursement for 99291 once per day when reported by physicians of the same group and specialty.8 Physicians of different specialties can separately report critical care hours as long as they are caring for a condition that meets the definition of critical care.
The CMS example of this: A dermatologist evaluates and treats a rash on an ICU patient who is maintained on a ventilator and nitroglycerine infusion that are being managed by an intensivist. The dermatologist should not report a service for critical care.6
Similarly for hospitalists, if an intensivist is taking care of the critical condition and there is nothing more for the hospitalist to add to the plan of care for the critical condition, critical care services may not be justified.
When different specialists are reporting critical care on the same day, it is imperative for the documentation to demonstrate that care is not duplicative of any other provider’s care (i.e., identify management of different conditions or revising elements of the plan). The care cannot overlap the same time period of any other physician reporting critical care services.
Calculating Time
Critical care time constitutes bedside time and time spent on the patient’s unit/floor where the physician is immediately available to the patient (see Table 1). Certain labs, diagnostic studies, and procedures are considered inherent to critical care services and are not reported separately on the claim form: cardiac output measurements (93561, 9356271010, 71015, 7102094760, 94761, 947629909043752, 437539295394002–94004, 94660, 9466236000, 36410, 36415, 36591, 36600).1
Instead, physician time associated with the performance and/or interpretation of these services is toward the cumulative critical care time of the day. Services or procedures that are considered separately billable (e.g., central line placement, intubation, CPR) cannot contribute to critical care time.
When separately billable procedures are performed by the same provider/specialty group on the same day as critical care, physicians should make a notation in the medical record indicating the non-overlapping service times (e.g., “central line insertion is not included as critical care time”). This may assist with securing reimbursement when the payor requests the documentation for each reported claim item.
Activities on the floor/unit that do not directly contribute to patient care or management (e.g., review of literature, teaching rounds) cannot be counted toward critical care time. Do not count time associated with indirect care provided outside of the patient’s unit/floor (e.g., reviewing data or calling the family from the office) toward critical care time.
Family discussions can be counted toward critical care time but must take place at bedside or on the patient’s unit/floor. The patient must participate in the discussion unless medically unable or clinically incompetent to participate. If unable to participate, a notation in the chart must delineate the patient’s inability to participate and the reason.
Credited time can only involve obtaining a medical history and/or discussing treatment options or limitation(s) of treatment. The conversation must bear directly on patient management.1,7 Do not count time associated with providing periodic condition updates to the family, answering questions about the patient’s condition that are unrelated to decision making, or counseling the family during their grief process. If the conversation must take place via phone, it may be counted toward critical care time if the physician is calling from the patient’s unit/floor and the conversation involves the same criterion identified for face-to-face family meetings.10