Yale Medical Group Medical Billing Compliance Department CRITICAL CARE SERVICES FREQUENTLY ASKED QUESTIONS

Transcription

1 Yale Medical Grup Medical Billing Cmpliance Department CRITICAL CARE SERVICES FREQUENTLY ASKED QUESTIONS Please see the current CPT manual regarding separate guidelines fr nenatal & pediatric critical care services (CPT cdes , , , & ) 1. What services are bundled with the Critical Care Cdes? The fllwing prcedures/services are included in reprting critical care when perfrmed n the day a physician bills fr critical care and therefre shuld nt be cded separately. The time spent perfrming these prcedures shuld be included in the physicians ttal calculatin f time when reprting critical care and shuld nt be subtracted frm reprted critical care time. CPT CODES DESCRIPTOR Intrductin f needle r intracatheter, venus Venipuncture, age 3 years r lder necessitating physician s skill (separate prcedure), fr diagnstic r therapeutic purpses (nt t be used fr rutine venipuncture) Cllectin f venus bld by venipuncture Page 1 f 7 Revised Cllectin f bld specimen frm a cmpletely implantable venus access device Arterial puncture, withdrawal f bld fr diagnsis Nas- r r-gastric tube placement, requiring physician s skill and flurscpic guidance (includes flurscpy, image dcumentatin and reprt) Gastric intubatin and aspiratin(s) therapeutic, necessitating physician s skill (e.g. fr gastrintestinal hemrrhage), including lavage if perfrmed 71010, 71015, Chest X-rays (see CPT fr specific definitins Temprary transcutaneus pacing 93561, Interpretatin f cardiac utput measurements (See CPT fr specific cde definitins) , 94660, Ventilatr management (See CPT fr specific cde definitins) 94760, 94761, Pulse Oximetry (See CPT fr specific cde definitins) Analysis f clinical data stred in cmputers (e.g. ECGs, bld pressures, hematlgic data)

2 2. What prfessinal services are included when Critical Care Time is calculated? The time spent with the critically ill r injured patient is cunted if the physician devtes his r her full attentin t the patient and, therefre, cannt prvide services t any ther patients during the same perid f time. Als cunted is the time the attending spent engaged in wrk directly related t the individual patient s care, whether that time is spent at the immediate bedside r elsewhere n the flr r unit (reviewing test results r imaging studies, discussing the critically ill patient s care with ther medical staff r dcumenting critical care in the medical recrd). When the patient is unable r clinically incmpetent t participate in discussins, the attendings time spent n the flr r unit with family members r surrgate decisin-makers btaining a medical histry, reviewing the patient s cnditin r prgnsis, r discussing treatment r limitatins(s) f treatment, prvided that the cnversatin bears directly n the management f the patient, can be cunted. The Center fr Medicare & Medicaid Services (CMS) requires the fllwing dcumentatin criteria be included in the recrd in rder t include this time in critical care services: The patient was unable r incmpetent t participate in giving a histry and/r making decisins as apprpriate. The necessity f the discussin (e.g., n ther surce was available t btain a histry r because the patient was deterirating s rapidly I needed t discuss treatment ptins with family immediately ) The treatment decisins fr which the discussin was needed The substance f the discussin as related t the treatment decisin Telephne calls t family members and r surrgate decisin-makers may be cunted twards critical care time, but nly if they meet the same criteria utlined abve. (Centers fr Medicare and Medicaid Services (CMS) Transmittal 1548) 3. What prfessinal services cannt be included when calculating Critical Care Time? Time spent in activities that ccur utside f the unit r ff the flr may nt be reprted since the physician is nt immediately available t the patient. Examples f services that cannt be included when calculating critical care time: Patient is transprted t anther area f the hspital fr an MRI and the physician des nt accmpany the patient Telephne calls, whether taken at hme, in the ffice, r elsewhere in the hspital Time spent in activities that d nt directly cntribute t the treatment f the patient Family discussins, n matter hw lengthy, such as peridic updates, emtinal supprt f the family, and answering questins regarding the patient s cnditin (nly questins related t decisinmaking regarding treatment as described abve, may be cunted tward critical care) Other services nt listed abve, shuld be reprted separately. Time invlved in perfrming prcedures that are nt bundled int critical care (cded and billed separately) shuld nt be included and reprted as critical care time. Page 2 f 7 Revised

3 4. Hw d I calculate Critical Care Time? The critical care evaluatin & management (E&M) service is a timed based service and des nt have the same dcumentatin requirements fr histry, exam, and medical decisin making as the ther E/M cdes. CPT cde is used t reprt the first minutes f critical care rendered t a given patient n a given date f service. It shuld be used nly nce per date even if the time spent by the physician is nt cntinuus n that date. It may be used t reprt the accumulatin f smaller blcks f time ttaling minutes that given date. CPT cde is an add-n cde and may nly be used in cnjunctin with It is used t reprt additinal blck(s) f time, f up t 30 minutes each beynd the first 74 minutes. See Critical Care Table n fact sheet, which illustrates the crrect reprting f critical care services. Time is cumulative fr any given service date. Fr example, a physician sees a patient in the ED at 1 a.m. and spends 35 minutes f critical care time with the patient. The patient is admitted t ICU, and tw hurs later the same physician is called t the ICU and spends anther 20 minutes f critical care time with the patient. Only assign a ttal f 55 minutes f critical care time fr that date f service (i.e., ne time nly). If the physician were t be called a third time t see the patient n that same date f service and was t spend anther 25 minutes f critical care time with the patient fr a ttal f 80 minutes, then, in additin t cde, shuld als be cded. The physician must dcument in the recrd the amunt f time spent prviding critical care services. This time cannt be inferred frm the physician s recrd. If the time is nt stated, the physician shuld be cntacted and asked what CPT cde is apprpriate fr the service. When cding critical care services, the time required t perfrm separately cded prcedures and services shuld be excluded frm the reprted critical care time. CMS states that this plicy applies t any prcedure with a 0-, 10-, r 90-day glbal perid including CPR (CPT cde 92950). These prcedures can be cded separately and in additin t the critical care cde. Intubatin and CPR are examples f a prcedure, and a service that, when perfrmed during critical care, shuld be cded separately and the time invlved perfrming these services shuld nt be included in the ttal critical care time reprted. When determining the amunt f critical care time t cde, include the time dcumented prviding critical care services, and then subtract the applicable time spent perfrming separately cded prcedures r services and then assign the apprpriate critical care cde(s) based n the remaining ttal time. The physician s prgress nte must dcument that time invlved in the perfrmance f separately billable prcedures was nt cunted tward critical care time. When prcedures are assigned in additin t critical care cdes, a mdifier -25 shuld be added t the critical care E&M service(s). If mdifier -25 is assigned t 99291; it must als be added t 99292, if apprpriate. The fllwing table is presented as a guideline nly fr cnsidering the minimal amunt f time it wuld take t perfrm the listed prcedure. This list des nt include every pssible prcedure that might be cded and the dcumentatin shuld always be cnsidered when evaluating prcedure time. Page 3 f 7 Revised

4 Subtracting Time fr Separately Reprtable/Nn-Bundled Prcedures frm Critical Care _ CPT CODES DESCRIPTION MINIMAL AMOUNT OF TIME TO PERFORM PROCEDURE Endtracheal intubatin 1 minute Transtracheal trachestmy, emergency prcedure Transtracheal trachestmy, cricthyrid membrane 1 minute 1 minute 32556, Thracentesis with insertin f 5 minutes catheter (32556). Tube thracstmy Pericardicentesis 3 minutes Temprary transvenus pacing 5 minutes Placement f needle fr intrasseus infusin 2 minutes Cardipulmnary resuscitatin Ttal time cmpressins are being perfrmed r ttal time between CPR start and CPR stp time dcumented in the recrd Rutine ECG with at least 12 leads; interpretatin and reprt nly 1 minute 5. Where can yu prvide Critical Care services? Critical care may be assigned fr prfessinal services delivered in any area as lng as all the criteria are met. Critical care is usually, but nt always, given in a critical care area, such as the crnary care unit, intensive care unit, pediatric intensive care unit, respiratry care unit, r the emergency care facility. Services fr a patient wh is nt critically ill but happens t be in a critical care unit are reprted using ther apprpriate E/M cdes (e.g. subsequent hspital visit cdes , r inpatient cnsultatin cdes ), depending n the level f service prvided. Examples that d nt satisfy Medicare s criteria fr critical care payment include: Patients admitted t a critical care unit because n ther hspital beds were available Patients admitted t a critical care unit fr clse nursing bservatin and/r frequent mnitring f vital signs Patients admitted t a critical care unit because hspital rules require certain treatments (e.g. insulin drips) t be administered in the critical care unit Page 4 f 7 Revised

5 6. Can an E&M (evaluatin & management) service be prvided n the same day as Critical Care by the same prvider? Critical care may, in rare circumstances, be assigned with anther E&M cde n the same day. When E&M services are furnished by a prvider earlier n a date at which time the patient did nt require critical care, and the same prvider (r prviders in the same grup f the same specialty) subsequently renders critical care, bth the critical care and the previus E&M service may be paid n the same date f service. When critical care services are required upn the patient s presentatin t the ED, then nly critical care cdes ( ) may be reprted. An ED visit cde ( ) may nt als be reprted. (CMS Medicare Claims Prcessing Manual, Chapter 12, Sectin , H ) Example: A 75-year-ld female arrives in the ED after a mtr vehicle accident, has multiple rib fractures and is experiencing respiratry distress. The ED physician prvides 35 minutes f critical care services. A trauma specialist is called t the ED, wh then assumes respnsibility fr the patient, and admits the patient t the SICU. The patient later suffers acute respiratry failure, and the trauma specialist prvides 40 minutes f critical care service. In this example, as lng as the critical care services are nt duplicative f each ther, and nt prvided during the same instance, and supprted by separate dcumentatin, the ED physician may reprt critical care service (99291), and the trauma specialist may reprt bth: E&M-Initial hspital care visit (99223-AI) and Critical Care service (99291). Nte: The dcumentatin shuld supprt the break in services, and the change in the patient s cnditin. If there is n break in services, bill nly the critical care services. [Surce: Medicare, Wiscnsin Physician Services, Facility Services (Q&As), 20 May 2014] 7. Can tw physicians prvide and bill Critical Care n the same date f service? If physicians are f different grups and/r specialties, they may each prvide and bill critical care services t the same patient n a given date, if the services are medically necessary, the cnditin each physician is treating and the care rendered meet the definitin f critical care, and the services are nt duplicative (see example abve). (Centers fr Medicare and Medicaid Services (CMS) Transmittal 1548 and Medicare claims prcessing manual, Pub , chpt 12, 30.6) If tw physicians f the same specialty, in the same grup, prvide critical care t the same patient n the same date, they must bill as if they were ne physician, cmbining their time and reprting and (if applicable) the apprpriate number f units f The initial critical care time billed as CPT cde must be met by a single physician r qualified APP. Example critical care billing fr tw prviders f the same specialty n the same day: Tw pulmnary specialists, wh share a grup practice, each prvide critical care services (at different times during the same day) t a patient wh has multiple rgan dysfunctin (including cerebral hematma, flail chest and pulmnary cntusin), is cmatse, and has been in the intensive care unit fr 4 days fllwing a mtr vehicle accident. Bth physicians may reprt Page 5 f 7 Revised

6 medically necessary critical care services prvided at the different time perids. One physician wuld reprt CPT cde fr the initial visit and the secnd, as part f the same grup practice, wuld reprt CPT cde n the same calendar date if the apprpriate time requirements are met. The CPT cde (critical care, first hur) is used t reprt the services f a physician prviding full attentin t a critically ill r critically injured patient frm minutes n a given date. Only ne unit f CPT cde may be billed by a physician fr a patient n a given date. Physicians f the same specialty within the same grup practice bill and are paid as thugh they were a single physician and wuld nt each reprt CPT 99291n the same date f service. Subsequent critical care visits perfrmed n the same calendar date are reprted using CPT cde The service may represent aggregate time met by a single physician r physicians in the same grup practice with the same medical specialty in rder t meet the duratin f minutes required fr CPT cde The aggregated critical care visits must be medically necessary and each aggregated visit must meet the definitin f critical care in rder t cmbine the times. Example critical care billing fr multiple prviders f the same specialty n the same day: Three pulmnary specialists, wh share a grup practice, each prvide critical care services (at different times during the same day) t a patient wh has multiple rgan dysfunctin (including cerebral hematma, flail chest and pulmnary cntusin. All physicians may reprt medically necessary critical care services prvided at the different time perids. The first physician wuld reprt CPT cde fr the initial 35 minutes f critical care service. The secnd, as part f the same grup practice, wuld reprt CPT cde X 1 after prviding 60 additinal minutes (25 mins added t initial 35 mins = 1 st hur f CC) f critical care services n the same calendar date, and the third physician, as part f the same grup practice, wuld reprt CPT cde X 2 after prviding an additinal 50 minutes n the same calendar day. If a physician r qualified APP within a grup prvides staff cverage r fllw-up fr each ther after the first hur f critical care services was prvided n the same calendar date by the previus grup clinician (physician r qualified APP), the subsequent visits by the cvering physician r qualified APP in the grup shall be billed using CPT critical care add-n cde The apprpriate individual NPI number shall be reprted n the claim. The services will be paid at the specific physician fee schedule rate fr the individual clinician (physician r qualified APP) billing the service. 8. Can Critical Care services be prvided and paid during preperative and/r pstperative perid f prcedures? A surgen can be reimbursed fr critical care services in the pst-p perid if the critical care criteria are met. Mdifiers -24 (unrelated evaluatin and management service by the same physician during a pstperative perid) r -25 (significant, separately identifiable evaluatin and management service by the same physician n the day f the prcedure) are required. Clear dcumentatin that the critical care was unrelated t the specific anatmic injury; r general surgical prcedure perfrmed; r was beynd the typical wrk f pre-r pstperative care assciated with the prcedure(s). Page 6 f 7 Revised

7 9. Can Critical Care services be prvided and paid during preperative and/r pstperative perid f prcedures in Trauma and Burn Cases? Critical Care services prvided during preperative prtin f the glbal perid f prcedure with 90-day glbal perid in Trauma and Burn Cases can be paid in additin t a glbal fee. In additin t mdifier 25, dcumentatin that the critical care was unrelated t the specific anatmic injury r general prcedure perfrmed must be submitted. An ICD-9-CM diagnsis cde in the range f thrugh (except ) that clearly indicates that the critical care was unrelated. Critical Care services prvided during pstperative perid f prcedure with glbal perid in Trauma and Burn Cases can be paid with critical care in additin t a glbal fee if critical care criteria are met and the critical care is unrelated t the specific anatmic injury r general surgical prcedure perfrmed. The mdifier -24 (unrelated E&M service by the same physician during a pstperative perid) must be used, and dcumentatin that the critical care was unrelated t the specific anatmic injury r general surgical prcedure must be submitted. An ICD-9-CM diagnsis cde in the range thrugh (except ) that clearly indicates that the critical care was unrelated t the surgery is acceptable dcumentatin. 10. Can qualified Advanced Practice Prviders (APP) prvide Critical Care services? Critical care services may be prvided by qualified APPs and reprted fr payment under the APP s Natinal Prvider Identifier (NPI) when the services meet the definitin and requirements f critical care services. The prvisin f critical care services must be within the scpe f practice and licensure requirements fr the State in which the qualified APP practices and prvides the service(s). Cllabratin, physician supervisin and billing requirements must als be met. A physician assistant shall meet the general physician supervisin requirements. (Centers fr Medicare and Medicaid Services (CMS) Transmittal 1548) 11. Is a Split/Shared Service permitted under the Critical Care guidelines? A split/shared E/M service perfrmed by a physician and a qualified APP f the same grup practice (r emplyed by the same emplyer) cannt be reprted as a critical care service. Critical care services are reflective f the care and management f a critically ill r critically injured patient by an individual physician r qualified nn-physician practitiner fr the specified reprtable perid f time. (Centers fr Medicare and Medicaid Services (CMS) Transmittal 1548) CMS guidelines indicate that physicians and APPs cannt cmbine time tward a single unit f critical care (e.g., 99291) but that they can bill individually fr sequential units (e.g r 99292(s). The service must be dne by ONE entity, and each must be dne by ONE entity, but the PA, MD, r thers must EACH ttally perfrm the unit f time he/she billed. Example: If 74 minutes f critical care is prvided by MD#1, the MD#1 bills and is paid fr 60 minutes f critical care time. If an APP then prvides 30 minutes f critical care, he/she cannt cunt the 14 minutes left frm the MD s time. If MD#2 f the same specialty/grup practice prvides 30 minutes f additinal critical care time, he/she can cunt the 14 minutes left ver frm MD #1. Page 7 f 7 Revised