Critical care Nursing specialists diagnose and treat a wide variety of diseases. A versatile team approach is needed to care for critically ill patients. Though there are only two codes for critical care services, reporting critical care presents a challenge because of the rules and regulations involved. In fact, Medicare and commercial payers inspect how critical care services are billed. Documentation of medical prerequisites is significant. Physicians can depend on expert coding and critical care medical billing services to bill critical care correctly.
Services must be medically essential and meet the essentials of critical care services. Care provided to patients that do not meet all of the criteria for critical care is reported using the suitable E/M code depending on the level of service provided.
Full Attention of Critical Care Provider
- Services need to be provided with the full attention of the provider.
- All-time reported should represent the time the provider actually evaluated, managed, and provided patient critical care.
- Critical Care Service providers should spend time with the patient’s immediate bedside, so long as the provider is immediately available to the patient.
- Even if more than one physician is providing care to a critically ill patient, only one physician or non-physician practitioner may bill for critical care services during any one time.
- The practitioner cannot provide services to any other patient during the same time period while providing critical care services to a patient.
Critical care is a time-based service
- Times spent may be continuous or an aggregate of intermittent by members of the same group and same specialty.
- The time demand of the initial critical care service must be met by only one physician or non-physician practitioner.
- Progress notes must document the total time the critical care services were provided for each date and encounter entry. In the case of multiple physicians, the documentation must support the medical necessity of the critical care services provided by each physician.
- Multiple physicians can provide critical care at another time and be paid if the service meets critical care, is medically necessary, and is not repeated care.
- Simultaneous care by more than one physician, generally representing different physician specialties is payable.
- Services not be shared/split between a physician and a non-physician practitioner.
Critical care coding services
- CPT code 99291 is used to report the first 30 – 74 minutes of critical care service.
- CPT code 99291 should be used once per calendar date per patient by the same physician or physician group of the same specialty.
- Physicians of the same specialty within the same group practice are billed and paid as though they were a single physician.
Non-physician practitioners of the same group
- Time is billed separately from the physician using the appropriate code.
- Physician time may not be combined with a non-physician practitioner of the same group practice.
- initial critical care code may not bill on the same day as the physician. Like, if the physician provides 30 – 74 minutes of critical care services, the non-physician practitioner will bill CPT code 99292 for the additional time up to 30 minutes.
- Physicians of a separate specialty may each report CPT code 99291 if they are providing care that is special to their individual medical specialty and managing at least one of the patient’s critical illness or critical injury.
- Critical care of fewer than 30 minutes total duration is not reported separately using the initial critical care CPT code (99291). This service should be reported using another relevant E/M code such as subsequent hospital care.
CPT code 99292
CPT code 99292 is used to report an additional block of time, of up to 30 minutes each beyond the first 74 minutes of critical care.
- Reporting CPT code 99291 is a prerequisite to reporting CPT code 99292.
- Includes “staff coverage” or “follow-up” even if a different specialty.
When it comes to critical care services, the red flags that will attract the attention of insurance carrier auditors are:
- Inaccurate coding
- Lack of medical necessity
- Insufficient or lack of documentation,
- Nonadherence to payer policies,
- Unbundling procedures included in critical care or overuse of modifiers can also trigger an audit.
Practices to reduce the risk of payer audits
The following best practices can reduce the risk of payer audits
- Well acquainted with Medicare and private payer rules and policies on billing critical care services.
- Ensure accurate and up-to-date CPT and ICD-10 codes in claims. For this, an experienced physician billing service provider can help you.
- Provide comprehensive documentation that supports the services that have been performed and billed.
- Make sure documentation can support medical necessity for all billed services.
- Perform regular self-audits of procedures and E/M coding and documentation for errors and areas of risk.
- Avoid overuse of critical care services, Unbundling services inappropriately with modifier 25 0r 59, billing for critical care when the patient does not meet the critical care definition, and other high-risk coding behavior.
Critical care billing and coding is a challenging task whether it’s using correct CPT codes or documenting medical necessity or documenting time. Allying with an experienced and professional critical care medical billing service provider is a practical way to make sure accurate reporting and avoid audits.
To know more about our critical billing and coding services, contact us at (224) 999-6997
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