How to Correctly Bill for Critical Care Time

Accurate billing for critical care services is important. These services are distinct due to the severe nature of a patient’s condition and the high intensity of physician involvement. Understanding critical care billing guidelines ensures compliance and appropriate reimbursement.

Understanding Critical Care

Critical care involves direct medical intervention for patients who are critically ill or severely injured. These patients experience acute impairment of one or more vital organ systems, leading to a high probability of imminent or life-threatening deterioration. The care demands continuous, high-level intervention and complex decision-making. Physicians must be readily available to assess, manipulate, and support vital organ system function.

The distinction between critical care and other high-level evaluation and management (E/M) services lies in the immediate, life-threatening nature of the patient’s condition and the intensity of physician involvement. Simply being in an intensive care unit (ICU) does not automatically qualify a patient for critical care billing; the services must specifically address a critical illness or injury that necessitates life and organ-supporting interventions. Examples of conditions requiring critical care include central nervous system failure, circulatory failure, shock, or respiratory failure.

Essential Elements for Billing Critical Care

For a service to qualify as critical care for billing purposes, several requirements must be met. A primary factor is the time spent directly managing the critically ill patient, which must be at least 30 minutes. This time includes direct patient management, evaluation, and treatment of vital organ system failure, whether continuous or aggregated from intermittent periods throughout a calendar date. Time spent on activities that do not directly contribute to the patient’s critical care, such as administrative tasks or teaching, is excluded.

The continuous presence of the physician or other qualified healthcare professional (QHP) is also a requirement. The provider must dedicate their full attention to the critically ill patient and be immediately available. During this critical care time, the provider cannot attend to other patients. The patient’s condition must exhibit medical necessity, meaning it is critical and life-threatening, requiring immediate attention to prevent sudden deterioration.

The care provided must involve decision-making of high complexity. This complexity is important for assessing, manipulating, and supporting vital organ system functions to treat or prevent further deterioration. High-complexity medical decision-making considers factors such as the number of diagnoses and management options, the amount and complexity of data reviewed, and the risk of significant complications or mortality. The physician’s thought process and the rationale behind interventions must reflect this high level of complexity.

Documentation for Critical Care Services

Documentation is important for supporting critical care billing. Time logs are required, detailing the start and end times of critical care provided. The total duration of critical care services must be clearly documented in the progress notes for each date of service. This documentation helps justify the time-based nature of critical care codes.

The patient’s critical condition must be clearly articulated in the medical record. Documentation should specify the vital organ system failure, the life-threatening nature of the illness or injury, and the high probability of imminent deterioration without intervention. Avoid generic statements, instead providing specific details about the organ system involved and the clinical rationale for critical care. This specificity substantiates the medical necessity.

All interventions performed, such as ventilator management or vasopressor titration, must be recorded. The documentation should also reflect the complexity of medical decision-making, outlining the physician’s thought process in managing the patient’s condition. This includes detailing the assessment, manipulation, and support of vital organ systems. Any time or services excluded from critical care time, such as separately billable procedures, should be documented distinctly to avoid confusion and ensure accurate billing.

Applying Critical Care Billing Codes

Once critical care services are rendered and thoroughly documented, specific Current Procedural Terminology (CPT) codes are used for billing. The primary code for critical care is 99291, which covers the first 30 to 74 minutes of critical care services on a given calendar date. For additional time beyond the initial 74 minutes, CPT code 99292 is used for each subsequent 30-minute block. It is important to note that 99291 can only be reported once per patient per calendar day by the same physician or physician group of the same specialty.

Calculating total critical care time involves aggregating all non-continuous time spent by the provider on a single calendar date. For Medicare patients, the full 30-minute increment must be met to bill an additional unit of 99292. For instance, if 80 minutes of critical care are provided, both 99291 and one unit of 99292 would be billed. If the total time is less than 30 minutes, critical care codes are not used, and the service should be reported with an appropriate evaluation and management code.

Certain services are considered inherently bundled into the critical care codes and should not be billed separately. These include, but are not limited to, the interpretation of cardiac output measurements, pulse oximetry, chest X-rays (professional component), blood gases, gastric intubation, and ventilator management. The time spent performing these bundled services is included in the total critical care time. However, services such as major surgical procedures or cardiopulmonary resuscitation (CPR) can be billed separately if performed and documented independently of the critical care time.

Specific Scenarios in Critical Care Billing

Billing for critical care can involve unique situations that require specific understanding. When multiple physicians from different specialties provide critical care to the same patient on the same day, each may bill for their services, provided they are managing distinct, life-threatening organ system failures and the care is not duplicative. Documentation must clearly support that each specialist’s care was unique and medically necessary.

Non-physician practitioners (NPPs), such as physician assistants and nurse practitioners, also play a role in critical care billing. They can provide critical care services and bill for them, often under supervision requirements. As of January 1, 2022, critical care services can be billed as split or shared services between a physician and an NPP from the same group, with the practitioner providing the substantive portion (more than 50%) of the time reporting the service.

Critical care services can be provided and billed in various settings, including the Emergency Department, Intensive Care Unit, or other inpatient settings. The location itself does not dictate whether critical care is billable; rather, it is the patient’s condition and the nature of the services provided that determine eligibility. If critical care is provided in the Emergency Department and the patient’s condition deteriorates to require critical care, only the critical care codes are typically reported, not both an emergency department visit code and critical care codes, unless the E/M service was separate and distinct from the critical care provided later.

Billing considerations also arise when critical care occurs during a global surgical period. Critical care can be billed separately during a global period if it is unrelated to the surgical procedure and the patient is critically ill. For Medicare billing, modifier FT is used for critical care services during a global period when the care is unrelated to the surgery. If the critical care is performed by a provider other than the surgeon in the postoperative period and is unrelated, it may also be separately billable.