Key Elements of Critical Care

Physicians should keep track of their critical care time throughout the day. Since critical care time is a cumulative service, each entry should include the total time that critical care services were provided (e.g., 45 minutes).10 Some payors may still impose the notation of “start-and-stop time” per encounter (e.g., 2–2:50 a.m.).

Same-specialty physicians (i.e., two hospitalists from the same group practice) may require separate claims. The initial critical care hour (99291) must be met by a single physician. Medically necessary critical care time beyond the first hour (99292) may be met individually by the same physician or collectively with another physician from the same group. The physician performing the additional time, beyond the first hour, reports the appropriate units of 99292 (see Table 1) under the corresponding NPI.11

CMS has issued instructions for contractors to recognize this atypical reporting method. However, non-Medicare payors may not recognize this newer reporting method and maintain that the cumulative service (by the same-specialty physician in the same provider group) should be reported under one physician name. Be sure to query the payors for appropriate reporting methods. TH

References

1. Abraham M, Ahlman J, Boudreau A, Connelly J, Crosslin, R. Current Procedural Terminology 2015 Professional Edition. Chicago: American Medical Association Press; 2014. 23-25.
2. Widespread prepayment targeted review notification—CPT 99291. Cahaba website. Available at: www.cahabagba.com/news/widespread-prepayment-targeted-review-notification-part-b/. Accessed December 17, 2015.
3. Critical care CPT 99291 widespread prepayment targeted review results. Cahaba website. Available at: https://www.cahabagba.com/news/critical-care-cpt-99291-widespread-prepayment-targeted-review-results-2/. Accessed December 17, 2015.
4. Prepayment edit of evaluation and management (E/M) code 99291. First Coast Service Options, Inc. website. Available at: medicare.fcso.com/Publications_B/2013/251608.pdf. Accessed December 17, 2015.
5. Medicare claims processing manual: chapter 12, section 30.6.12A. Centers for Medicare & Medicaid Services website. Available at: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed December 17, 2015.
6. Medicare claims processing manual: chapter 12, section 30.6.12B. Centers for Medicare & Medicaid Services website. Available at: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed December 17, 2015.
7. Critical care fact sheet. CGS Administrators, LLC website. Available at: www.cgsmedicare.com/partb/mr/pdf/critical_care_fact_sheet.pdf. Accessed December 17, 2015.
8. Same day same service policy. United Healthcare website. Available at: www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Main%20Menu/Tools%20&%20Resources/Policies%20and%20Protocols/Medicare%20Advantage%20Reimbursement%20Policies/S/SameDaySameService.pdf. Accessed December 17, 2015.
9. Medicare claims processing manual: chapter 12, section 30.6.12G. Centers for Medicare & Medicaid Services website. Available at: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed December 17, 2015.
10. Medicare claims processing manual: chapter 12, section 30.6.12E. Centers for Medicare & Medicaid Services website. Available at: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed December 17, 2015.
11. Medicare claims processing manual: chapter 12, section 30.6.12I. Centers for Medicare & Medicaid Services website. Available at: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed December 17, 2015.