Billing and Documentation Update-Billing and Documentation

Billing and Documentation

Video Transcription

Hello, and welcome to today's webcast, Billing and Documentation Update.  My name is David Carpenter. I'm the Co-Director for Quality and Patient Safety at the Emory Critical Care Center and a Physician Assistant for Emory Health Care.  I'm the moderator for today's webcast. A recording of this webcast will be available five to seven business days after the webcast.  Log into mysccm.org and navigate to the My Learning tab. Click on Billing and Documentation Update, and then click on the Access button to access the recording.  You'll also find the full slide deck available for review. A few housekeeping tip items before we get started. There's a Q&A at the end of the presentation.  To submit questions throughout the presentation, type in the question box located in your control panel.  You'll also have the opportunity to participate in several interactive polls. When you see the poll, click the bubble next to your choice. And finally, we have a quick survey.  Discovery has launched the Priorities for Research in Critical Care Illness Survey, or PRECISE, an inclusive survey for all critical care stakeholders to identify critical care  research priorities. The goal is to involve all critical illness and injury stakeholders.  If you could please scan the QR code and take five minutes to complete the survey and provide your feedback.  This presentation is for educational purposes and is intended to present an approach, view, statement, or opinion of the presenter that may be helpful to others.  The views and opinions expressed are those of the presenters and do not necessarily affect the opinions of SCCM.  SCCM does not endorse or recommend any specific test, position, product, procedure, opinion, or other information that may be mentioned.  With that, I'd like to introduce our speaker today. Deb Greider is the Executive Consultant at Care and Zookote Associates in Chicago and  is a well-respected coder for a number of years and an author of American Medical Association coding books. I'd like to turn that over to Deb now. Thank you. Thank you, David.  Hello, everyone. Today, we're going to talk about critical care. The codes have not changed. The guidelines have not changed since last year, but there are a few updates, and a lot  of what we're going through is probably just a refresher, but it's always good to have a refresher.  First of all, the Medicare Physician Fee Schedule Final Rule came out in November, and it reduced our payment, our conversion factor, by 2.93% in 2025 from 2024.  We did have an increase from last year and a 0.2% adjustment in the RBUs, the work relative value units, and that has since gone away in 2025.  In 2025, our conversion factor went from 33.29, which it is today, to 32.35, so you'll see that reduction of 2.83%. Medicare has targeted critical care.  Critical care has been on the OIG work plan since 2019. They are getting ready to finalize their final report.  They have a couple of reports out on the OIG work plan in relation to critical care services, and what the OIG is saying, that Medicare has paid $2.4 billion in critical care from  the period of 2017 through March 31st of 2019, and then through the Comprehensive Error Rate Testing Program, CERT, they found that in 2018, the improper payment error rate was  19.7% or $198 million, and Medicare does pay for critical care that meets certain requirements,  so one of the requirements is that documentation has to support the critical care service. It has to be medically necessary, and you have to spend a minimum of 30 minutes per  day for a date of service in order to report critical care, and they also use, when they're  looking at, when they're analyzing this data, they use data mining, data analyst techniques,  and they've identified through the Office of the Inspector General that an area of concern is critical care coding, high overpayments, and there's a risk for noncompliance with  Medicare billing requirements, so with that said, we just had the CMS improper payment rates  released this morning for 2024. In 2021, we had $196 million in projected improper payments, and that was just for CPT code 99291, which is your primary critical care service,  and then 22.9% was due to insufficient documentation, whereas 72.2% overall improper payment rate due to incorrect coding. Well, the report released this morning,  and I was frantically reading through the entire report to pull out the information about critical  care. Improper payment rates for 2024 related in $207 billion, $306.411 improper payments,  so that's approximately $270 million, 12.6% with no documentation, so that means that documentation was requested and not submitted, 20.5% with insufficient documentation, whereas  in 2021 it's 22.9%, so it's gone down a little bit, 0% for medical necessity, meaning that they  couldn't find any reason why the services weren't medically necessary of the documentation they  reviewed, 66.1% incorrect coding, which is reduced, and now we have a 17.2% overall error rate  for critical care services, and that just includes 99211. They did not do an analysis on 99212 in  this report. That report can be found on the CMS.gov website in its entirety, and I recommend  that everybody read it because it does contain important data, including your hospital services.  So, one of the examples that the OIG found that wasn't critical care, this was a surgical patient  had graft thrombosis of the left lower leg. They had a surgical procedure, a lower extremity bypass graft thrombectomy, no complications, and they were put in the ICU.  Well, Medicare paid $382. They paid over two days, 99291, so they paid for day one 99291, day two 99291, and a GC modifier was appended to this claim, and that means that there was  an attestation that the service was performed under the direction of the teaching physician by a resident, but when they looked at the documentation, they realized that there were  no complications, no rationale for reporting critical care. The patient had routine post-operative  care provided. They were just in the ICU because it was a precaution that they closely watched.  No acute distress, stable vital signs, and it was determined that the documentation did not  support the presence of an illness or injury that acutely impaired one or more vital organ systems,  or there was a high probability of imminent or threatening deterioration in the condition of the  patient, and also they found the medical record did not indicate the teaching physician was engaged  in working directly related to patient care at the immediate bedside or was immediately available  on the floor, so they reduced the service from a 99291 to 99232, and there was a 255 difference  between the Medicare payment for a 99232, which is a subsequent hospital or observation care service,  down to $125, so this is just one example that they looked at, so they actually look at documentation  when they do this analysis for the CERT program, the comprehensive error rate testing, and this  gives them insight into what they need to look at for audit in the future, so Medicare will  continue to audit and monitor critical care as well as other payers do. So let's look at adult  critical care thresholds versus CMS critical care thresholds. Of course, 99291 and 99292 are based on time. The first 30 to 74 minutes is 99291. Each additional 30 minutes is 99292,  and the units are based on a total time per date of service, so the actual time that is spent by  either you, the physician, or your PA or nurse practitioner, or your partner during that date of  service, and that time is cumulative, and if you're managing the same problem for that patient.  So, less than 30 minutes, we bill an E&M code, so you can see here on this table  that the units are based on how much total time during the day. For Medicare, it's a little bit  different. If it's less than 30 minutes, it's another appropriate E&M code, so that could be  an initial hospital or observation care code, 99221 to 223, or it could be a subsequent hospital  care code observation, inpatient or observation 99231 to 233. If it's 30 to 74 minutes, you can  bill 99291. Now, in order to bill for a 99292, you have to meet at least 104 minutes, so you have to  go to the top of the threshold. So, if you're at 75 minutes for commercial payers and payers  who follow the CPT rules, you can bill 99291 and 99292. For Medicare, you have to be at 104 minutes,  so you have to go to the top of the threshold in order to bill 99292 with one unit. So, documentation  is critical to add that time. It doesn't have to be continuous time. It can be non-continuous time  during that date of service for any medically critical care service that you provide, and again,  private payers, commercial payers typically have their own policies. They typically follow CPT rules.  There are some payers that follow Medicare rules, so you need to know what rules do these payers apply.  So, when should you not use critical care? If the patient's in ICU and they don't meet the definition  of critical care, and critical care is actually the definition is that you're providing a high  level of care for a patient who's medically unstable, they have a critical illness or injury,  or there is probability of an imminent issue that might arise in a nutshell. If they don't meet the definition of critical care, they're put in critical care because they need to be  closely watched. That does not constitute a critical care code. That would constitute  more than likely a subsequent hospital care code. Or for patients during the post-op global period  whose critical care is related to the surgery, and that would be the surgeon, if it's another  condition that's not related to the surgery and critical care is provided, then it can be reported.  If critical care does not exceed 30 minutes, you report a subsequent hospital E&M code 992312233  based on either medical decision making or time. Or if you're rounding in the critical care unit for a patient not meeting critical care requirements, it's a subsequent hospital  care code. If it's not related to an operative procedure during the non-global care, so it would  be subsequent care. So if you're rounding in the critical care unit and they don't meet the  requirements. So for example, if you are changing vent settings or you're managing the vent, that  doesn't necessarily mean that you're managing the critical portion of the care, you're just managing  the vent itself. So for patients receiving palliative care, critical care does not apply. That would be a subsequent hospital if they're in the hospital setting.  So what's included in the calculation of critical care? So first of all, providing service at the  patient's bedside, discussing the patient's condition with other physicians or other members of the care team, if you're on the unit and immediately available,  reviewing data related to the patient while on the unit and immediately available,  performing procedures bundled into critical care. And I will review those in just a moment. Discussing with the family only if you're obtaining a clinically relevant history  that the patient is unable to give. So for family discussions, you should document that the patient  is unable or incompetent to participate. Don't always assume that we would know that if we're  auditing records. And I've been a consultant since 1997 and I've audited thousands of critical  care services. And if you don't tell us the rationale behind it, you don't get credit for  it during an audit and a payer will do that as well. So the patient's unable to participate in  giving the history or making treatment decisions and it's relied on upon the family. The necessity  to have the discussion so there's no other source available. You're making medically necessary  treatment decisions for which the discussion was needed. And you need to summarize in the  medical record a summary of that discussion and document the time that you spent. So that time  that you spent getting that information to determine how to treat the patient or managing the patient clinically counts towards time for critical care. Now if you're just giving  them an update, it does not count. Writing notes in the chart when on the unit. So if you're in the  EHR and you're documenting notes, you're giving orders to the nursing staff, then that would be  considered part of the critical care management. What does not count? As I said before, updating family members. You're not obtaining a history or anything that can help you manage  the patient's critical issues. Teaching time, time spent off the unit, time caring for other patients,  time spent on phone calls, any activity that doesn't contribute to the patient's critical care.  If you're performing a procedure, that procedure has to be carved out. So when you're documenting  a procedure, as well as your critical care service, let's say you're performing a procedure  at the bedtime, in your documentation, document your total critical care time and make a note  saying in your note, excluding whatever procedure you perform. I'm excluding that time. Or you might  want to document total time for critical care, total time for the procedure. You could do it  either way. And time spent in typical follow-up care for the patient is not included. So if you're  doing typical follow-up, like rounding, and you're not managing the critical portion of the patient's  care, you're not looking at labs, you're not making treatment decisions that are critical  for that patient, it doesn't count. And then for Medicare patients, time that you spend treating  complications does not count in the critical care time. Services that are bundled into critical  care. Now these are bundled. You cannot report these codes separately. However, it does include  the critical care time. So you can count the time that you're doing this. So any interpretation of  cardiac output measurements, chest x-rays, pulse oximetry, blood gases, any physiologic data that  you're collecting, interpreting, reviewing, gastric intubation, a TTP, vet management,  peripheral vascular access procedures, those are all considered included that you cannot bill  separately. So if you're doing anything else, then you can bill for it separately. But the  time counts towards these procedures as part of your critical care. These are just some examples,  not all inclusive. Endotracheal intubation, the swan's dance catheter, CPR is not bundled into critical care and it can be reported separately. So it's a good idea if you're  doing CPR, you exclude it from critical care, document the time you spent on CPR versus critical  care. Chest tube insertion, TTP, that is considered services that can be billed separately. So make sure again that you document the time of the critical care exclusive  of the services that you're billing and carve that out.  Now, full attention of the physician must happen for critical care services. So the actual time that you're managing, evaluating, providing care directly to the patient  counts towards the time. You cannot be providing services to other patients. Once you leave that  patient and go to another patient, that time stops. You must be immediately available to the patient either at the bedside or somewhere on the unit in order to provide critical care  or bill for critical care. And time counted for critical care does include ordering, reviewing lab tests, discussing the patient with physicians  or other medical staff in the unit, nursing staff, even if it doesn't occur at the bedside, as long as you're providing full attention  to managing a critically ill or injured patient.  So let's talk about concurrent care. Your advanced practice providers are your partners and an APP is considered to be in the same specialty and subspecialty, even though they have  their own specialty code, they are considered to be one in the same as you are if they are working with you or under you. And they're considered the same specialty or subspecialty  regardless of their taxonomy code.  They can't provide concurrent follow-up care subsequent to another practitioner's critical care. It might be continuous staff coverage, follow-up care,  and the time is aggregated to meet the time requirements. So if you have a Medicare patient and you spend 35 minutes managing the care in the morning,  and let's say your PA comes in the afternoon and manages another 15 minutes, that would be 45 minutes. That would be the total time for that date of service  for both of you to provide the critical care.  And we'll talk about who you bill it under in a few moments.  So same specialty physicians or advanced practice providers. Here's an example where you have a physician who sees a critically ill patient for 45 minutes.  The PA manages it for 34 minutes. Now, if this is a non-Medicare patient, you would report 99291 for the first 30 to 74 minutes,  and then 99292 for each additional 30 minutes. So we have actually 79 minutes here.  So we could report 99292 because we have 45 minutes for the physician, 34 minutes for the PA. And as far as who bills for the service,  it's the one who provides a substantial portion or 50% of the time for the critical care service. So in this instance, it would be the physician.  Now for Medicare, you'd have to have 104 minutes. So you could only report 99291 in this example.  So if you're a different specialty, so you have cardiology and pulmonology working managing the same patient for different reasons, and both conditions are critical.  If the service meets the definition of critical care for your specialty, then more than one physician can provide concurrent care. But it has to be medically necessary,  and it must be non-duplicative, meaning that you can't be doing the same thing, providing care for the same problem. So here's an example where the cardiologist  is in managing an acute MI for 66 minutes, and the patient's developed a pulmonary embolism. Pulmonologist is called in to manage that portion of the care and spends 45 minutes.  So each would report 99291. Of course, their specialty code or taxonomy codes are different. So it shouldn't be a problem in getting those claims paid properly.  So critical care can be reported on the same day as another E&M service  if the visit is medically necessary and it's provided before the critical care time. So let's say the patient comes in, they're admitted to the hospital.  Let's say that they had a stroke, and the physician did a CT scan, and they did an MRI. The ER doc admitted the patient to the hospital. They're put under the neurologist for care,  and the patient's stable.  And let's say later in the day, they have another stroke, and now they're critical, and their condition meets critical care definition.  So the initial inpatient or hospital care code would probably be reported for the initial care, 99291 to 29221 to 223.  And then later in the day, they're critical. Now you can report the E&M service with modifier 25  for the critical care service that says it's significantly separately identifiable. Now, if the critical care occurs before, and then they're not critical,  and they're put on a floor, or maybe they're transferred, their status changes, you cannot do it backwards. It has to be they're stable, they're in the hospital,  they're being managed, and now they're critical. Or they were in the office, you saw them, they're being managed, they go home, now they go to the hospital, now they're critical.  Then you could report both services on the same date with modifier 25.  I didn't confuse you on that one.  So here's an example. Patient admitted as an inpatient with severe chest pain, shortness of breath. So let's say they're admitted by the ED doctor to the hospitalist  or the cardiologist, and the cardiologist will bill that E&M service based on medical decision making or time. So let's say the bill of 99223. And later in the day,  they're summoned because the patient had an acute MI. So now they're transferred to critical care, their status changes, they meet the definition of critical care.  So the physician would bill the 99223 for the initial visit, and then 99291 for the first 30 to 74 minutes, they spent 45 with the modifier 25. And that indicates it's significantly  separately identifiable. So both E&M services should be paid. And Medicare, this is a rule that Medicare does allow. They do allow both services if it meets that definition.  Well, what happens when critical care continues to the next day? So since critical care is time dependent, and let's say you're managing the patient at 1145 at night,  and then it's continuous, you're continuously managing that patient until 1210 the next calendar day. The date that you start the patient management would be the date of service,  and that time would be continuous. So when you start managing the critical care, when you end managing the critical care the next day after midnight.  So all that time would be accumulated or aggregated.  But let's say that the patient,  you were responding to their need for critical care services at 1145 at night, you spent until let's say 1159, and then the next day you go in  and you're managing the critical portion again, that's a new date of service.  It's non-continuous, so it would start over. So be sure that you document if you have a continuous service to the next day, the circumstances related to the continuous service,  that's important. So here's an example where we have a 45-year-old patient admitted to neural ICU, had a motor vehicle accident at 1115. They were admitted on November 15th.  Critical care physician provided intervention from 1115 to 1245. From 1115 to 1245 on November 16th, all that time is aggregated and counted as one service.  And the date of service would be November 15th.  So they provided continuous care for 90 minutes. So they would report 99291 and 99292 for each additional 30 minutes since it was 90 minutes. And the patient's 45,  so typically they wouldn't be a Medicare patient.  If they were a Medicare patient, you could only report 99291 because you have to reach that 104-minute threshold to bill for Medicare for 99292,  which I know isn't fair and I don't agree with, but this is the rule that we have to follow.  So now let's look at this example. We've got the 45-year-old patient, same patient admitted to 1115 on November 15th. We have our intervention provided by the physician,  the neuro-ICU physician from 1115 to 1245.  And then the service stopped at 1245. So we're going to bill for 1115, 99291 and 99292. And now the patient has deteriorated on November 16th. And that was at 9 a.m. to 945.  And so there were 45 minutes spent stabilizing the patient. So again, we are going to report on November 16th, 99291 for that 45 minutes. And then on November 15th, 99291 and 99292  for the continuous service.  So if it's a split shared service, so let's go back to talking about split shared. And that's when you have a physician and an advanced practice provider providing services.  You're in the same group, same specialty.  In the hospital setting, a facility setting,  a split shared visit is allowed for hospital E&M services, critical care and skilled nursing. It is not allowed for office visits for Medicare,  but from the AMA CPT definition, it is. And if you have questions about that, you can ask.  So whoever spends the majority of the time on the date of service reports the service, regardless of how you're paid, who gets paid more.  So of course, if you have an advanced practice provider, a PA, a nurse practitioner managing the patient for Medicare, you receive 85% of the allowed amount  on the physician's fee schedule, the Medicare physician fee schedule. If you bill under the physician, you receive 100%. However, since critical care is a time-based service,  then whoever spends at least 50% of the time  and accepts responsibility for managing the care plan, you bill for that service based on who spent the most time. If you're using medical decision-making,  it's based on who approves the care plan and takes responsibility and manages the risk for that care. And that would be your hospital codes 99221 to 223.  And then if you're billing a hospital service, if you're using data like reviewing records, reviewing labs, doing an independent interpretation,  discussing management and test interpretation with other practitioners, whoever performs majority of that, who performs all of that, would get credit for the level of service.  So that's for your hospital E&M. But for critical care, it's who spent 50% of the time. And that's a substantive time for CMS. And for split share, you must append modifier FS  to your claim and whoever bills for the service must sign the note or co-sign the note. So it's always a good idea that everyone sign their own notes when they're providing  critical care services. That time is aggregated and whoever spent the most time. So you'll have to look at the note and make that determination.  So the physician and APP must be in the same group. They're working jointly to furnish work related to the patient encounter. They may not be hospital employees.  They must be employed by your group or contracted with your group to provide services to your patients. They have to see the patient at different times.  If you see the patient together, only one of you counts the time. If you're in different groups or different specialties, each bills their own service independently.  And time spent by two practitioners jointly seeing the patient, only one, again, as I said before, counts the time. And the substantive portion is billed  by the practitioner who bills the majority of the time or 50% or more. Physician is paid 100% of the allowable for Medicare. The advanced practice provider is paid 85%.  For your commercial payers, it depends on whether the payers follow CMS split shared rule, how they pay, whether it's usual and customary, but there is a reduction in payment  always for the advanced practice provider.  So for split share documentation in the medical record, must identify the practitioner who performed the visit.  Practitioner who provided the substantive portion will sign and date the medical record, electronically, of course, we're all on EHRs now,  and document the time,  even if only the practitioner who bills must sign the note and use modifier FS for the split shared. And that's whether it's a hospital visit,  99221 to 233, or a critical care service, 99291 or 99292. Modifier FS must be appended. So here's an example where the cardiologist  is managing a patient in the critical care unit for an MI. 45 minutes, the patient's worsening. Later in the day, the APP, cardiology APP provides 30 minutes.  So that would be 75 minutes. So the physician bills 99291 because the physician provided the substantive portion for the first 30 to 74 minutes.  And the APP would not bill. And the time is all billed under the physician's NPI number because they spent the majority of the time.  So global surgery and critical care. So typically, if you're doing surgery, the rule is for global surgeries, if you're the surgeon  and you are moving the patient into critical care, and even if they are critical, that critical care service is included in your global surgical package.  Unless it's unrelated to the critical care. So here's an example where the physician or partner of the same specialty repairs a lacerated liver after a trauma.  Physician manages the patient's other injuries, a hemothorax in this ICU for 40 minutes. And only time spent managing the unrelated procedure. The hemothorax is unrelated.  They would bill 99291. And the FT modifier is necessary because that tells the payer it's an unrelated E&M service during the post-operative period.  If you do not append that FT modifier and submit that claim, the claim is going to automatically kick out and be rolled into the global package.  So that's important. So it's not appropriate when it's related to the surgery during the global package and you're the surgeon. Here's an example, patient becomes hypotensive  after abdominal surgery, patient becomes hypotensive after abdominal surgery due to hemorrhage at the surgical site. That's considered part of managing the care.  Physician manages the patient during the post-op period following a Whipple. Physician manages the fluids and nutritional needs  and monitors for complications and outdoor critical care. Physician manages post-operatively the vital signs, metabolic status, because the patient has comorbidities  that might increase complication. Again, that's included in the global package. And you have to keep in mind that certain complex surgical procedures  have critical care days that are valued in the code by the rub.  So critical care documentation should always include the organ system at risk. So your documentation should paint the picture of the patient's condition.  Your history is so important. Medically necessary, it drives every patient encounter. So telling the story supports medical necessity.  So the Comprehensive Error Rate Testing Program, they've always identified the fact that medical necessity of the service is the overarching criterion for payment  in addition to the components of the CPT code.  So diagnosis coding is also important. Listing all your diagnoses that you're managing, all the conditions you're managing and the complexity of those conditions,  the severity of those conditions,  what therapeutic or diagnostic interventions were performed, what lab tests did you review, what did you order? All of that is significant.  And your course of treatment, your plan of care. And lastly, if there's any likelihood of life-threatening deterioration, document that because that supports it.  Because without that intervention, sometimes a payer might look at your critical care note and say, no, that's not critical care. But if they know there's a likelihood of that,  then the next time that they look at a note for your critical care service, it would be supported. And time spent on adult critical care must be documented.  Of course, your pediatric critical care per diem per date of service. Critical care for adults are patients over five years of age and that would be time-based.  So I'm going to turn over now to David and he will go through three cases with you.  Thank you very much.  So I won't read through the whole thing, but the first case is an 80-year-old woman with a past history of Parkinson's disease, chronic kidney disease, hypertension,  arthritis, and glaucoma.  Came in with abdominal pain and hematokesia.  Relatively normal looking,  except for the cratinine, relatively normal looking labs.  So the patient developed essentially septic shock, given two liters of crystalloid, was started on norepinephrine and vasopressin.  A central line, no terminal line were placed.  So does this note support critical care or other E&M care?  Okay, so 70% said critical care, 30% said other E&M care. Some of the people may be thinking that we didn't share time, which is true.  So if your time was somehow under 30 minutes, not including the procedural time for all that, then yes, it would be E&M.  But you have, you know, the base definition of critical care is the patient you're supporting one or more organ systems to prevent failure or death.  So the vasopressors alone would be enough to get critical care the way it's documented.  So a 78-year-old woman presents to the emergency department with an injured right knee. She had a trip and fall, injuring her right knee.  She had medical history includes alcohol use, tobacco use, CAD, status post to cabbage, colon cancer, status post to colectomy, hypothyroidism, depression, GERD,  and sorry, a total knee arthroplasty times two. She has a periprosthetic distal femur fracture with a small amount of hematoma.  So she was treated in the ED, intubated for general anesthesia. They basically opened up the hematoma. She got a liter of LR, 500 of albumin.  That was all before the current shortage of IV fluids and was started on some neosynephrine. She was extubated. Shigavidex was given, and she went to the PACU.  Her saturations were low. She was having difficulty breathing. She had a non-rebreather and a bag valve mask, and then she had a chest radiograph.  The oxygen in the PACU was eventually weaned to 4.5 liters. She was never on pressers in the PACU, and then she went to the ICU normal intensive on 4 liters nasal cannula.  So does this support critical care?  Okay, yes, so the patient was probably critically ill in the PACU, but assuming that, you know, this is a different service that's treating her in the PACU,  by the time she got to the ICU, she's not critically ill, so other E&M care would be appropriate here. And then last, 83-year-old presents the emergency  department with her daughter after falling. She has a history of Parkinson's disease, dementia, hypertension, hyperlipidemia, GERD, and hypothyroidism.  She travels frequently. She was tired from a recent trip, fell, hit the back of her head on a baseboard. No loss of consciousness. She has been having more  frequent falls, which they blame on an increase in her Parkinson's medication. She takes baby aspirin. Other than that, no anticoagulation. She has a small  laceration in the back of her scalp, which was closed with glue and ED. CT shows a trace of arachnoid bleed in the left paraphosphine frontal lobe.  Neurosurgeons consulted and advised this Keppra 500 milligrams twice daily for seven days, and repeat CT. She's admitted to the ICU for close neurologic monitoring.  Okay, does this support critical care or E&M?  Okay, so about a 50-50. So what I tried to do with these is have one that was definitely critical care, one that was definitely not, and then, you know, this  falls into the gray area. However, you know, given the documentation and what's before us, you're not actually, you're observing the patient closely, but the  patient hasn't become critically ill. For example, if this bleeds and she seizes and has to be intubated, then you would convert from E&M to critical care, but I  think as written, you know, she's in the ICU for close neuromonitoring for ICU nursing care, but you have to differentiate that from critical care. So  I would say that this is not critical care. So with that, we'll open this up to questions. We have a number of them. Thank you very much. Thank you, Deb, for a great  job. I'm gonna let Deb answer the first one, because, so there was a number of questions about Medicaid and critical care, like which time, which time  documentation do they use, the Medicare guidelines or the commercial insurance guidelines? Well, that's a good question. That depends on your state, so I can't  really answer that with Medicare or commercial, but a lot of states follow Medicare's guidance, and some of them have added additional requirements in  their policies. So the best thing that you can do is have a staff member or you as a physician want to look up your state Medicaid policy on critical care, I  would do that, and follow your state policy for Medicaid. So again, I wish I could answer that yes or no, it's Medicare or commercial, but I can't  because it's a state-by-state issue. Yeah, and to make it even more confusing, if you're in a Medicare HMO, you may follow Medicare guidelines or you may follow the  commercial payer guidelines. Right, right. So let's see, so I think we clarified for Medicare patients, you need 104 minutes or greater. For commercial patients, it's  105. For 99292? Yeah, 99292. For commercial payers, it's 75 minutes for 99292. And there was a question, I think just to clarify, and then for Medicare, it's 104  minutes to get the 99292. Correct, for 99292. They went to the top of the threshold, whereas commercial payers typically do not. Yeah. CPT says at 75 minutes, you can  bill a 99292. Medicare says you have to have 104 minutes. And they created that in the Medicare Physician Fee Schedule Final Rule in 2022. They  reinforced it in 2023, and they made no changes in 2025. So we are stuck with that rule. Yeah. Can you explain what duplicative element means in regards to  E&M and critical care on the same day? I'm sorry, could you repeat that? Can you explain what duplicative element means in regards to E&M and  critical care on the same day? Okay, duplicating services. So if the cardiologist and the pulmonologist are working together, as the example I showed  you, one is handling the pulmonary failure or embolism, and the other is handling the acute MI, there are different reasons. If you're managing a  patient for the same reason, only one can bill for that. So you would need to have two separate diagnoses. So if cardiology, their diagnoses would be the acute MI  based on the type of MI, and the pulmonary embolism diagnosis would be the pulmonologist bills. So that would be concurrent care. They're both working,  managing a critical patient, but for different reasons. Yeah, actually I think what they were talking about was if the patient isn't critically ill and then  becomes critically ill. So taking the example of the neurologist, if the patient is critically ill, you couldn't bill critical care for all the things that you did under the E&M  adding, right? Prior to them becoming critical, it's an E&M, a 99221-233 depending on the circumstance, medical decision-making or time. If they become  critical later after that encounter that you had with the patient where you did the evaluation, if they become critical later, then you bill critical care with  a 25 modifier, and all the time you spend from the time that you're managing that critical portion counts towards the time. But you can't count what happened before.  You have to bill both E&Ms. Let's see, so two questions here that are kind of related. Are we going to present for the pediatric population?  No, we're not. We had to kind of cut this to make it under a time limit, and that's kind of what part of the part that got cut. To answer the  question for shared services for critically ill four-year-olds, if I'm remembering my pediatric critical care billing, and I'm not the expert, it's a  global package for the entire day, so it really doesn't matter if there's no real shared services per se. It all just goes under the physician. Yeah, but you  could split share the service between a physician and, let's say, a PA. You could split it, but you would only report that, like you would do an E&M service, the  actual service. So, for example, if you're providing critical care to, let's see, let me pull up a code here. The specific code was 99475. Okay, 99475, so that's a  hospital care per day, and if you have a physician managing the patient, and then the PA managing the patient later on, you would have to combine those  services, and whoever performs a substantive portion, and based on the guidelines, whoever makes, formulates the plan of care and takes ownership and  responsibility for that patient and the risk bills for the service, and you would use modifier FS for split share. Yeah, and then, let's see, a couple questions. So, I  mean, you know, correct me if I'm wrong, Deb, there's a question. I thought the potential for immediate deterioration accounted for critical care in a  traumatic subarachnoid hemorrhage with the potential for deterioration. My reading, what I was taught on this, is that it's the actual deterioration  that constitutes critical care, not the potential. Is that correct? Correct. Okay, and then, following on the neuro, for a neuro-ICU patient, if they  receive IV thrombolytics after a stroke and get admitted to the neuro-ICU, can the diagnostics and medical decision meet the critical care  code? And the answer is yes, but you get that. So, if this all happened in the ED, then the ED can build critical care, but if the patient doesn't have a critical  illness that needs, you know, they haven't seized, they're still breathing, their blood pressure is okay, you know, they don't have an acute  intervention to save an organ system or life, and you're just doing neuro-monitoring after TPA, then no. Is that correct? That's correct. Documentation, in that instance, is  really important. Yeah. To tell the story of what's occurring and when it occurred and how it occurred. Okay, here's a CT-ICU. If I'm managing a patient in the CT-ICU  following a CABG, providing fluid resuscitation and manage the ventilator and extubate the patient, does it mean that this is bundled into the surgical  code for the CABG? Yes, that's bundled. But I thought it was only bundled if the surgeon was doing all those things. Okay, I guess I misunderstood you. I  thought the surgeon was. If it's not the surgeon, you could build critical care, but that's gonna create some red flags and the payers going to say  why isn't the surgeon managing this? Yeah, although that also kind of recognizes that Medicare has not caught up with the realities of how, you know,  critical care works. It's not all of CABG patients. It's actually only a very, I think it's only down to like four or five codes now. Is that correct? Yes.  There's actually very few CABG procedure, cardiac surgery procedures, that have critical care bundled into them and Medicare is doing its best to kind  of get rid of this for this exact problem. Right, right. And later on, maybe in 26 or 27, they'll change the ruling and allow critical care for  management after surgery. Yeah. If managing a ventilator, which is still okay in time, is no longer considered critical care than for a surgical patient in the  post-op period, in a surgical critical care unit, can the intensivist use E&M codes for vet management? And the primary surgeon has global  period limitation. Right. If it's a surgeon, it's considered inclusive. Yeah. But it's got to be an expected outcome of the  surgery. And there's very few surgeries where the expected outcome of the surgery is acute hypoxic failure requiring ventilation. Correct. Right,  right. And also... If the patient becomes critical and they have to be put on a vent and it's unrelated, that's part of the critical care time. Right. So  usually... And there's also the whole thing about billing for post-surgical hypoxic failure, which is kind of a CMS indicator. But that actually  doesn't occur until two days after the surgery, or 48 hours after the surgery. So to answer the question directly, you could bill E&M codes while  if the primary surgeon is doing the vent management, which I would say is  pretty rare. Yeah. Most surgeons are not intensivists, probably outside of trauma surgery. So for the most part, the surgeon would be in managing surgical  wounds and resuscitation, and you would be managing the ventilator and whatever other critical care needs. So that could still be billed critical care.  That could be billed critical care, and that management would be part of that critical care service. Okay, this is a little complicated, but we do this.  For clarification, if an E&M doc and the critical care bill for acute respiratory failure with hypoxia, the patient is admitted to the ICU on the  same day, and is seen by another E&M doc who is critical care trained, can the E&M doc bill critical care for acute hypoxic respiratory failure?  So you've got, who's involved in the case? You have an E&M doc in the ED who bills for acute hypoxic respiratory failure. A critical care trained E&M doc in the ICU  who is seeing the patient in the ICU. Okay, so is the ED doc managing that critical portion? Well, they are in the ED. Okay, they could bill critical care if  they're managing that critical portion, and if the patient's transferred to the ICU and the care is taken over by another practitioner, they could bill for  critical care because they're a different specialty. It might trigger an audit from any payer, and so it would have to be clearly documented an  explanation of what happened, what occurred. Yeah, the other thing, so physicians are allowed to have two specialty codes. So ideally, the  physician is listed in both the critical care faculty, however that gets, you know, whatever department that is under, or if it's its own department, and then it's  also listed in the E&M faculty. So the E&M bills with the physician specialty for emergency medicine, and the E&M critical care trained doctor bills with the  physician specialty of critical care. That helps separate those out when it comes to looking at them from a billing standpoint. Yeah, it does help separate  it out, but I know the payers are pretty sophisticated with their data mining, especially if, you know, if it's an inpatient hospitalization, they look at  from a MIT through discharge at all the documentation. So if they caught it and it was audited and they looked at the documentation, if it's clear, they should  pay it. So to clarify, performing a critical care consultation, and it does not require critical care, this is an E&M code and not critical care time-based.  Okay, if you're doing, if you're doing a consultation, for maybe what reason? So some places have critical care consult teams, so they go to the patient and  are they critically ill? Do they need the ICU? If they say no, then it's just regular E&M. Regular E&M. Yeah. If they're just a consultant and they're not managing the  critical portion of care, and they're just a consultant making that determination, it's a hospital E&M. Okay, let's see, here we go. Daytime  intensiveness bills 99291 and 992 for 90 minutes of care. The overnight intensivist ends up delivering 40 minutes of critical care. Does that  40 minutes get added to the 90 minutes or separately? Well, now the hospital intensivist is going to bill under the hospital, correct? No, these are, these are  just, these are like intensivists covering the ICU. Okay, and they're billing that, billing under their own NPI number and their own specialty code,  because their specialty code is different. Again, you're in that situation where you have two different specialties managing the patient for the same problem, and  that's where you have to really be careful with your documentation. Yeah, so somebody just clarified, they're the same specialist, but there, it's basically the,  it's follow-up care, right? So it's 130 minutes total. It would be billed under the physician that billed the 99291 and did the 90 minutes. You would bill,  let me see if I can do math, you bill 99291 and 299292s under the first physician, the one that did the most care. Correct, correct. So it's all  under one practitioner if you're in the same group and same specialty. Yeah, and if you, if you change the practitioner to intensivist to APP for 40  minutes, then you would still bill under the physician, and you'd still bill, this is assuming that this is all not Medicare. If it's Medicare, you'll bill one less 99291, and  then if it was flipped around, and there was 90 minutes of care by the APP and 40 minutes by the intensivist, then you would still, and it's, well, and this is the  other thing we didn't really talk about, and we are, this is probably the last question. Commercial player, payers still follow the, the older guidelines and  don't necessarily credential APPs. Right. So most of them will actually bill the entirety of the time under the physician. Right, for commercial payers that don't  recognize the APPs, you bill under the physician, and even the ones that do accept them, like Anthem and Cigna, you, you still have to bill under the  physician, because their policy states that, but for Medicare, it's whoever spends the most time, so you're right. For commercial, if this was an APP going 90  minutes and intensivist with 40 minutes, then you would actually bill the 99291 and one 99292 under the APP at 85%. For Medicare, that would be correct.  All right, well, I would like to thank everybody, and thank Deb for an incredible talk, and hopefully we'll get to do this again sometime fairly soon. Appreciate  the questions, appreciate everybody's attention. Thank you very much. Thank you.

Video Summary

In a recent webcast, David Carpenter of Emory Health Care discussed critical care billing and documentation updates, emphasizing Medicare's 2025 changes which include a nearly 3% reduction in payment conversion factors. Co-presenter Deb Greider detailed critical care billing specifics, highlighting the importance of accurate documentation to meet Medicare's stringent requirements. She explained that reporting critical care requires a minimum of 30 minutes of documented time for services like organ system support and interactions essential for patient management. She noted that non-critical time, like updating family members or documentation off the patient's unit, does not count towards this time. The guidelines differ between Medicare, which requires 104 minutes to add a 99292 code, and commercial payers needing 75 minutes. Both stressed the need for clear differentiation between non-critical E&M services and critical care within documentation. Key points include coding bundled with critical care, concurrent care billing, and split/shared visits between physicians and advanced practice providers. The webcast concluded with a Q&A session addressing various scenarios and their billing implications, underscoring the complexity of these guidelines.

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