Medically necessary critical care services provided on the same calendar date to the same patient by physicians representing different medical specialties that are not duplicative
services are payable. The medical specialists may be from the same group practice or from different group practices.
Critically ill or critically injured patients may require the care of more than one physician medical specialty. Concurrent critical care services provided by each physician must be medically necessary and not provided during the same instance of time. Medical record documentation must support the medical necessity of critical care services provided by each physician (or qualified NPP). Each physician must accurately report the service(s) he/she provided to the patient in accordance with any applicable global surgery rules or concurrent care rules.
CPT Code 99291
The initial critical care time, billed as CPT code 99291, must be met by a single physician or qualified NPP. This may be performed in a single period of time or be cumulative by the same physician on the same calendar date. A history or physical exam performed by one group partner for another group partner in order for the second group partner to make a medical decision would not represent critical care services.
CPT Code 99292
Subsequent critical care visits performed on the same calendar date are reported using CPT code 99292. The service may represent aggregate time met by a single physician or physicians in the same group practice with the same medical specialty in order to meet the duration of minutes required for CPT code 99292. The aggregated critical care visits must be medically necessary and each aggregated visit must meet the definition of critical care in order to combine the times.
Physicians in the same group practice who have the same specialty may not each report CPT initial critical care code 99291 for critical care services to the same patient on the same calendar date. Medicare payment policy states that physicians in the same group practice who are in the same specialty must bill and be paid as though each were the single physician. (Refer to the Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, §30.6.)
Physician specialty means the self-designated primary specialty by which the physician bills Medicare and is known to the contractor that adjudicates the claims. Physicians in the same group practice who have different medical specialties may bill and be paid without regard to their membership in the same group. For example, if a cardiologist and an endocrinologist are group partners and the critical care services of each are medically necessary and not duplicative, the critical care services may be reported by each regardless of their group practice relationship.
Two or more physicians in the same group practice who have different specialties and who provide critical care to a critically ill or critically injured patient may not in all cases each report the initial critical care code (CPT 99291) on the same date. When the group physicians are providing care that is unique to his/her individual medical specialty and managing at least one of the patient’s critical illness(es) or critical injury(ies) then the initial critical care service may be payable to each.
However, if a physician or qualified NPP within a group provides “staff coverage” or “follow-up” for each other after the first hour of critical care services was provided on the same calendar date by the previous group clinician (physician or qualified NPP), the subsequent visits by the “covering” physician or qualified NPP in the group shall be billed using CPT critical care add-on code 99292. The appropriate individual NPI number shall be reported on the claim. The services will be paid at the specific physician fee schedule rate for the individual clinician (physician or qualified NPP) billing the service.
Clinical Examples of Critical Care Services
1. Drs. Smith and Jones, pulmonary specialists, share a group practice. On Tuesday Dr. Smith provides critical care services to Mrs. Benson who is comatose and has been in the intensive care unit for 4 days following a motor vehicle accident. She has multiple organ dysfunction including cerebral hematoma, flail chest and pulmonary contusion. Later on the same calendar date Dr. Jones covers for Dr. Smith and provides critical care services. Medically necessary critical care services provided at the different time periods may be reported by both Drs. Smith and Jones. Dr. Smith would report CPT code 99291 for the initial visit and Dr. Jones, as part of the same group practice would report CPT code 99292 on the same calendar date if the appropriate time requirements are met.
2. Mr. Marks, a 79 year old comes to the emergency room with vague joint pains and lethargy. The ED physician evaluates Mr. Marks and phones his primary care physician to discuss his medical evaluation. His primary care physician visits the ER and admits Mr. Marks to the observation unit for monitoring, and diagnostic and laboratory tests. In observation Mr. Marks has a cardiac arrest. His primary care physician provides 50 minutes of critical care services. Mr. Marks’ is admitted to the intensive care unit. On the same calendar day Mr. Marks’ condition deteriorates and he requires intermittent critical care services. In this scenario the ED physician should report an emergency department visit and the primary care physician should report both an initial hospital visit and critical care services.
Q1. Please explain how critical care is not billable in a moment of crisis. If care is delivered in a moment of crisis or emergently, is this not considered critical care?
Critical care is defined as the direct delivery by a physician(s) medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition.
and Critical care services encompass both treatment of "vital organ failure" and "prevention of further life threatening deterioration of the patient's condition." Therefore, although critical care may be delivered in a moment of crisis or upon being called to the patient's bedside emergently, this is not a requirement for providing critical care service. The treatment and management of the patient's condition, while not necessarily emergent, shall be required, based on the threat of imminent deterioration (i.e., the patient shall be critically ill or injured at the time of the physician's visit).
As indicated, if critical care is given in a moment of crisis, or if a provider is called to the patient's bedside based on a potential that the patient's health is in serious jeopardy, or to avoid serious impairment or dysfunction, these points do not meet the requirement for providing critical care: "vital organ failure" and "prevention of further life threatening deterioration" are not universally evident in these scenarios. Care provided during a "moment of crisis" or "upon being called to the patient's bedside emergently" may result in critical care being provided - for each case, documentation should indicate the medical necessity of the level/type of treatment.
Additionally, 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.
Q2. In cases where both the physician and non-physician practitioner (NPP) provided critical care on the same day, regardless of who saw the patient first (physician/NPP), could the physician report 99291 (if the time was met) or would 99291 need to be reported under who saw them first?
A. In regard to critical care services, the CMS IOM does not make distinction regarding who sees a patient first. A split/shared E/M service performed by a physician and a qualified NPP of the same group practice (or employed by the same employer) cannot be reported as a critical care service. Critical care services are reflective of the care and management of a critically ill or critically injured patient by an individual physician or qualified non-physician practitioner for the specified reportable period of time and shall not be representative of a combined service between a physician and a qualified NPP.
Medicare will pay for services reported with Current Procedural Terminology® (CPT®) codes 99291 and 99292 when all the criteria for critical care and critical care services are met. When CPT® code time requirements for both 99291/99292 and critical care criteria are met for a medically necessary visit by a qualified NPP, the service shall be billed using the appropriate individual National Provider Identifier (NPI) number. Medically necessary visit(s) that do not meet these requirements shall be reported as subsequent hospital care services.
Medically necessary critical care services provided on the same calendar date to the same patient by physicians representing different medical specialties that are not duplicative services are payable. The medical specialists may be from the same group practice or from different group practices.
Critically ill or critically injured patients may require the care of more than one physician medical specialty. Concurrent critical care services provided by each physician must be medically necessary and not provided during the same instance of time. Medical record documentation must support the medical necessity of critical care services provided by each physician (or qualified NPP).
Q3. Can you clarify the circumstances when an E/M service can be billed on the same day as critical care?
A. When critical care services are required upon the patient's presentation to the hospital emergency department, only critical care codes 99291-99292 may be reported. An emergency department visit code may not also be reported.
When critical care services are provided on a date where an inpatient hospital or office/outpatient E/M service was furnished earlier on the same date at which time the patient did not require critical care, both the critical care and the previous E/M service may be paid. Hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician to the same patient.
Physicians are advised to submit documentation to support a claim when critical care is additionally reported on the same calendar date as when other evaluation and management services are provided to a patient by the same physician or physicians of the same specialty in a group practice.
Q6. If a physician provides/documents a critical care service (99291) in the morning, and later in the day sees the patient again, documenting a 99292 service, would both services be reimbursed?
A. Critical care is a time-based service, and for each date and encounter entry, the physician's progress note(s) shall document the total time that critical care services were provided.
The CPT® critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous. Non-continuous time for medically necessary critical care services may be aggregated. Reporting CPT® code 99291 is a prerequisite to reporting CPT® code 99292, which is an add-on code.