Hello, and welcome to today's webcast, Billing and Documentation Update 2020. My name is Piyush Mathur, and I'm the co-chair of SCCM's Billing and Documentation Knowledge Education Group, and I'll be moderating today's webinar. A few housekeeping items before we begin. There is no CE associated with this educational program. A recording of this webcast will be available in five to seven business days. To access, log into mysccm.org and navigate to the My Learning tab to access. To submit questions throughout, type your question into the question box on your control panel. Q&A will be held at the very end, so please be sure to enter your questions in as we go along. SCCM provides the following disclaimer. This presentation is for educational purposes only. The material presented is intended to represent an approach, view, statement, or opinion of the presenter, which may be helpful to others. The views and opinions expressed herein are those of the presenter and do not necessarily reflect the opinions or views of SCCM. SCCM does not recommend or endorse any specific test, physician, product, procedure, opinion, or other information that may be mentioned. And now, I'd like to introduce your speaker, Deborah Greider. Deborah is a senior consultant with Karen Zupko and Associates and author of AMA Coding Books. She's also the author of the Critical Connections Coding Corner articles and has spoken and consulted on coding across the country. I will now turn the presentation over to Deborah. Deborah, please take it away. Thank you very much, Dr. Mathur. Good afternoon, everyone. Today, we're going to be talking about critical care. We'll start with talking about adult critical care services and end up, at the end, talking about the new E&M services for 2021 for office or other outpatient for your post-acute critical care patients that a lot of you are involved in. So, you can see the learning objectives here. We're going to talk about what's included in critical care. Documentation is really important in validating medical necessity. One thing to keep in mind is that the critical care services have been on the OIG, the Office of the Inspector General's work plan, since 2018 and will continue in 2021. So, your services are consistently being audited by CMS and other payers to make sure your documentation supports medical necessity for critical care. We'll also talk about the other E&M services for your initial hospital care and your subsequent hospital care services, as well as you can also build consultations if you're the consulting physician. And then, talk about the COVID-19 pandemic and the critical telehealth or the telecritical care services. And CMS just came out yesterday evening, in fact, with the Physician Fee Schedule Final Rule for 2021, which does address telehealth for critical care. And then, we're going to, at the end, like I said before, we're going to talk about the new clinic office visits for office or other outpatient, if you are seeing patients either in your office, if you're a specialist who does that, as well as we'll just give you a slight overview if you're managing patients in your post-acute critical care setting or clinics. And let me get back to the slide. So our agenda, we're going to start with medical necessity, we're going to end with the office or the E&M services for 2021, just an overview, because that presentation alone itself was about three hours, if you want to get more in depth with it. What can be included in critical care? We're going to look at some documentation, good and bad, and talk about that in this webinar session. One thing to keep in mind, that your CPT is copyrighted by the American Medical Association, and that relative value units, conversion factors, those are components of CMS and not the American Medical Association. So they don't assume any liability for data that's contained in any of those documents. So let's start talking about medical necessity and why it's so important. You know, CMS has said for many years, since the Federal False Claims Act came along, that medical necessity is the overarching criterion for selecting a level of service or a type of service, whether it be an E&M service, a critical care service, a procedure. When we're talking about critical care, if you're rounding on a stable patient, it probably would not qualify for critical care. If you're not managing a critical portion of the service, it's typically not. So one of the most important requirements to receive payment for services and to establish medical necessity is that you have to justify the care that you provide. And payers require that documentation supports knowledge of the emergent nature or severity of the patient's complaint or condition, signs, symptoms, complaints, any background facts, any comorbidities that affect management of the patient care should be documented. And you need to substantiate the rationale, the need for care, whether it's direct or it's indirectly stated. And then the facts have to be substantiated in the documentation and made available to the payer on request. Now, that's for Medicare, that's for Medicaid, that's for Anthem, Cigna, United, any payer, commercial payer, as well as Medicare. So medical necessity is important. So some things that you should ask yourself when you're documenting or when you're reviewing your note, does your documentation support that a patient assessment and the services you provided supported vital system function? That's key for critical care. Does it also support that you were either at the bedside or immediately available on the unit? If you have family discussions, was the patient present with those family discussions and did they participate? And if they're unable to participate, did you document the reason they're unable to participate, well known? And then any discussions or things that are necessary relative to determine medical necessity or treatment decisions need to be clearly documented. And documentation is the key, it's the devil's in the details, so to speak. So here's some examples of what justifies medical necessity if you're managing these services and the patient is not stable and you have to manage them. So critical care, it encompasses both treatment of vital organ failure and prevention of further life-threatening deterioration of the patient's condition. And critical care is delivered in a moment of crisis or upon being called emergently to the patient's bedside, even though this is not a requirement for critical care. If you're managing a patient's condition, if it's not emergent, if it's based on a threat of imminent deterioration when the patient is critically ill or injured at the time of the visit, it would support critical care. Some questions come up, what if the patient's on a ventilator in the ICU? That doesn't necessarily mean they're critical status. If they're stable, or if a patient's admitted to a critical care unit because no other hospital beds were available, or maybe you're monitoring them for a drug for toxicity, but they're not really critical, those would be examples of when critical care would not be supported. But here are some examples you see on the screen that would be. Another example, if a patient has a partial pressure of oxygen and it's dropping and it requires your immediate attention to evaluate the problem, make treatment adjustments, that would be a critical patient. So those are just a few examples. So let's talk about coding for critical care. As we know that critical care is time-based, 99291, 99292, those are adult critical care codes reported for patients who have reached their fifth birthday. So from 2 to 5 would be a pediatric critical care code, the adult critical care code starts after that. 99291 is for the first 30 to 74 minutes, and 99292 is each additional 30. Now for 2021 to know, there are no changes in the critical care guidelines from the AMACPT perspective. There have not been changes to the critical care guidelines for CMS. As of yet, not to say that there won't be or might be, but currently we're using the same guidelines as we did in 2020. So documentation of time is important. So this actual slide here, this information is available in this AMACPT codebook if you ever need to reference that. So what is critical care? The AMACPT and Medicare have a little bit different language as to what critical care is. Critically ill or critically injured patient, both Medicare and the AMA agree on that definition. It impairs one or more vital organ systems, they both agree on that. And for Medicare, there is a high probability of imminent or life-threatening deterioration, as in the AMACPT. So there's really not any differentiation in the definitions. When we're looking at critical care involves high-complexity decision-making to support vital system functions. Some examples you can see here on the left-hand side of your screen for Medicare, like central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, or respiratory failure. Those are just examples, not all inclusive. And then this slide for patients who are critically ill or unable, there's a high probability of threatening or further deterioration, which qualifies as critical care service. Critical care service can be provided on multiple days, even if no changes are made in treatment. If that statement is still true, if there is a high probability of imminent life-threatening deterioration. So when should you not use critical care codes? If the patient does not meet that definition of critical care, so if you're administering infusions or insulin infusions to a patient who's not really considered critical, maybe they have diabetes and it's not stable, but is it at the critical status? Patients who are in the unit for observation for whether or not they're monitoring for drug toxicity or not, those wouldn't be considered critical. Patients in the postoperative global period, if the surgeon is providing the post-op care directly related to the surgery, that's not considered critical. That's bundled into the postoperative global days for the procedure. And then if you don't meet that minimum 30-minute threshold, so if you spend 15 minutes with the patient managing their critical care service for that date of service on that same date, then you would bill either the initial hospital care code, if that's your first visit, or the subsequent hospital care codes. And if you're rounding, if a patient is stable, they're on a vent, but they're stable, there's not a high imminent probability that their condition will deteriorate, you're not going to bill critical care, you're going to bill the subsequent hospital care codes, 99231 to 99233, if it's not related to an operative procedure. Now if it is related and you're the surgeon, then it would be considered bundled into the surgical procedure. So let's look at a couple of examples here. We've got a patient called, you're called to the emergency room, or you're called emergently, excuse me, to the patient's bedside, patient's hypovolemic, hypoxic, you realize organ system is clearly at risk, your immediate intervention is required. Critical care is supported for 30 minutes, you would report that as 99211 for the first 30 to 74 minutes. So now they're in the emergency department, critical issues, may be ventilator dependent, you round daily, make appropriate clinical treatment adjustments. If it's unrelated to surgery and supported by the documentation, if there's an imminent threat of deterioration, it's critical care, if there's not, it's a subsequent hospital care code. So there's that real fine line that you have to pay attention to, and again, the devil's in the documentation, as long as your documentation supports that need. And even though you know from a clinician standpoint, think about it, your medical record could be audited by a payer, how do you know that payer's got that clinical skill that you do to be able to assess that appropriately? So you want to make sure it's very clear. Here's another example, patient in the ICU stable, moving towards discharge to the next level of care, no intervention or organ system issues remain, it would be subsequent hospital care, or it would be non-billable if you're the surgeon providing post-op care, or if you decide to discharge that patient today, it would be a discharge code 99238 to 99239, depending on how much time you spent. So here's what's included in critical care, and probably for a lot of you, this is just a review, but it's always good to review at least on an annual basis. So providing services at the patient's bedside, discussing the patient condition with other physicians or members of the patient care team when you're on the unit. Now if you're off the unit, you can't count it towards critical care. Now we're going to talk about the telehealth, telecritical care services, that's a little bit different, and we'll talk about that, but that's not related to the in-person critical care management, so keep that in mind. Reviewing data related to the patient on the unit, performing procedures bundled into the payment for critical care. So if it's part of the critical care package, where that service is included, the time counts. Discussing with the family only if you have to get information to manage patient care. So if you're not needing to give information, you're just giving them an update on the patient's status or condition, that does not count. And writing notes in the chart, that could be the electronic health record on the unit, but you have to be immediately available to the patient. I had a physician once, I do a lot of work with critical care doctors, I shadow them so I have a better understanding of what services that you provide. And there was a physician that asked me a question that I thought was very interesting. He was at home at night, somebody from the ED called him, he was a critical care doctor. He managed the patient for an hour and a half in his bedroom on the side of his bed and wanted to build critical care. Well, unfortunately, we would not be able to build critical care because you have to get up, get dressed, to go to the hospital and manage the patient face-to-face. So this happened a couple years ago. So in that instance, you can't bill for anything. So just keep that in mind, you have to be on the unit. Services that can't be included in critical care, things that don't count are updating the family members, teaching residents or med students, researching the patient's condition, time spent off the unit, time spent caring for other patients, time performing procedures that you can bill separately for. And it's always a good idea to keep those notes separate. Keep your critical care notes separate from your procedure note, even though it might be on the same encounter, just separate them out so it's clear. And time spent in typical follow-up for all patients. So if you're doing rounding that day and the patient's not in imminent danger of deterioration, that would not be part of critical care. And treating complications for Medicare patients. If you're the surgeon and it's a complication related to the surgery, it's considered part of the global. Some other payers will allow payments separately for that, but for Medicare, it's inclusive. Services included in critical care. There's quite a few cardiac output measurement interpretations, chest x-rays, pulse oximetry, gastric intubation, TTPs, vent management, peripheral vascular access, that's all included in the critical care code. And again, the time devoted to any one of these activities should be added to your critical care time. Here's an example of some services that can be billed separately. They're not included in the critical care. This is just a snippet. There's an all-inclusive list. This is not all-inclusive. But some of the common things like a swan's glands catheter, an endotracheal intubation, CPR is not included. If the patient crashes and you have to get the code blue team in and you're performing the CPR, that's a billable service separate from critical care. Inserting a central line, chest tube, periocardiosynthesis, a TTP, and again, not all-inclusive. But document your time exclusive of the critical care. Okay, as I just said, CPR is not bundled into critical care. And you need to document the time separately or exclusive from the critical care. So what do the guidelines say? They say the time reported for critical care should be actual time spent evaluating, managing, and providing care directly to the critically ill or injured patient. And that means you have to give them your full attention. So let's say you're rounding in critical care and you've got five critical care patients in the unit that they meet the definition of critical care. Just make sure that you keep the time. And it's a good idea to keep a notebook with you and jot down the time you spent for that patient. So later on, if you're not actually in the electronic health record between patients, you'll be able to differentiate that. When you're providing critical care to one patient, you cannot provide services to another patient. You have to be immediately available on the floor. That's the time that counts. If you're reviewing labs, discussing the patient, let's say you've got hospitalists who are staffing the critical care unit and you come in and you meet with the hospitalist and go over the patient's condition and review the labs. All of that is inclusive of critical care as long as you have full attention to that particular patient. Any time spent off the floor unit does not count towards critical care. Also concurrent care by more than one physician. And that's usually different specialties if the criteria for critical care. So let's say you're a pulmonologist managing the respiratory failure. The patient was in stress. You're managing that. The patient has congestive heart failure. Let's say they're having some problems with their heart. And the cardiologist in critical care doctor goes in and manages that portion. There are two separate reasons. That's concurrent care that can be built separately. Your diagnoses are going to be different. Even though you might diagnose secondarily the CHF or the comorbidities, your primary diagnosis, your first list of diagnosis needs to be why you're managing the patient care. And that's critical in being able to support necessity. And a lot of critically ill patients do need the support of multiple physicians because usually they have multiple medical problems. And they have to be medically necessary. They can't be the same duplicating medical record documentation has to support that. And each of you would have to accurately report your service to make sure it's appropriate. So the physician specialty would be either your specialty code, which now we call the taxonomy code, to differentiate your separate specialties. So more than one provider providing critical care. Initial critical care 99291 must be met by a single physician or a qualified APP. Now APPs have their own taxonomy specialty code now. But they may be assigned to your specialty. So you have to look at both of those pieces when you're looking at critical care. Now for an APP, your advanced practice professionals, you cannot split share a visit. Each would report their services separately. If you have a physician, 99291 for the first 30 to 74 minutes can be performed in a single period of time, or it can be cumulative on the same calendar date by that physician. And again, you have to meet for Medicare the first 30 to 74 minutes before you can use the add-on code 99292. So 99291 is reported once per day by a physician in the same group having the same specialty. Only once. Any additional services provided by the same specialty on the same date of service would report 99292. The aggregate critical care visit has to be medically necessary and each visit must meet the definition of critical care and must represent the aggregate time. So only one doc can report 99291. So here's an example. Physician number one provides critical care, meets the time documentation criteria. Physician's partner comes in later in the same day, meets the definition for critical care, would report 99292 under their own NPI number. So you have different specialties, same or different group. You could be part of a large group, but you could be a multi-specialty group. So you have cardiology, you have pulmonology, you have thoracic surgery, you have otolaryngology. So you have all different specialties. If you're in the same group but you're a different specialty, you can each build the initial critical care code the first time as long as it's medically necessary. So the example here is we have the thoracic surgeon provides critical care one time period for a thoracic issue, meets the definition of critical care. Trauma surgeon provides critical care for a different clinical reason. Both would build that service. If they're in the same group but they're a different specialty, each would report 99291. Okay, physicians or APPs in the same group practice with different specialties who provide critical care may not always each report the initial critical care code. As I said earlier, you know, the APPs now have their own taxonomy specialty code, but they might be assigned to cardiology, for example. So they're part of that cardiology group. So they may not be able to report 99291 if they see the patient second after the physician. Some payers don't look at it the same way, so you have to look at it payer-specific. Some payers require each to bill their own initial hospital care code or initial hospital critical care code. It depends on the payer, but for Medicare, they don't allow it. And then, so if a physician or qualified APP within a group provides staff coverage or follow-up for another group physician, then it's 99292. Now if they're in different groups or they're in the same group but a different specialty, each would report 99291. So let me throw this example out. You've got Physician A sees the patient in the morning. He is a cardiologist, bills 99291, meets the definition of critical care. The APP is assigned to trauma, and they would bill 99291 for if it's a different reason and it meets the definition of medical necessity for critical care, because even though they're in the same large group, they're assigned, they're in different specialties. Okay, concurrent care, it usually represents different specialties. We talked about that earlier. It has to be medically necessary, and Medicare will not pay for duplication. So that's just kind of a reminder there. So let's talk about the 90-day global. Now let's say you're the surgeon. We'll use trauma as the example. So you see a patient preoperatively and postoperatively of the global period. You can report it during those periods if the critical care is not related to the surgery. So here's an example. Physician repairs a lacerated liver after trauma. You're managing the patient's other injuries in the ICU. Those other injuries might be able to be billed as unrelated problems if they're not related to the reason for the lacerated liver repair. And you would use modifier 24, which is an unrelated E&M service during the post-op period. Now you have to have a different diagnosis with modifier 24. So just keep that in mind. So the guidelines for global services and critical care indicate that E&M services that are directly related to the surgery are included in the global package. So if you have a global package of 90 days, so for 90 days you have to provide the postoperative care for that surgical procedure, it's all inclusive, even critical care services. If you're treating hemorrhages, infections, monitoring a patient whose surgery involved a threat to metabolic or other organ systems, that may not necessarily be rationale for billing critical care separately. But if you have complications that occur postoperatively or life-threatening arrhythmias that pop up that you weren't expecting or any respiratory issues that aren't the result of the surgery and it meets the definition of 30 minutes or more, definition of imminent threat or deterioration, possible deterioration, then you can report the critical care separately. So when it's not appropriate, let's look at these examples. Patient becomes hypotensive after an abdominal surgery due to hemorrhage at the surgical site. That's related. Patient manages a patient during the post-op period following a Whipple after blunt abdominal trauma. You're managing the patient's fluid and nutritional needs and monitor for complications. That's included. Or you're managing the patient postoperatively in the ICU, vital signs, metabolic status, and you're monitoring them closely because they have comorbidities that might increase the likelihood of complications that would not be considered critical care. That's included in the postoperative surgical procedure. And there are certain days valued in the codes depending on whether it's considered a minor procedure, which is 0 to 10 days, or a global day procedure, 90 days. So just as a reminder, if the encounter is unrelated to the postoperative global service, bill for it. Keep in mind that you need to know are other physicians reporting critical care for the same problem. That could be an issue with the payer because they monitor that. Payers would expect a different diagnosis if both are reporting critical care. I don't think I've seen during audit situations where they haven't. And they may request documentation to support medical necessities. So they may request cardiology and pulmonology's documentation if they're both managing a patient for critical care during an audit situation. And one thing to keep in mind, critical care can only be reported by one physician during that time period. So let's say you go in and see the patient at 10 o'clock, you're the pulmonologist, and you're still managing the critical care at 1015, and in comes cardiologist at 1014 and wants to manage the cardiac condition. You can't do it. She's got to wait until you're finished because you can't have overlapping times. This question came up, gosh, about a year ago in one of the sessions I was doing for critical care. Patients critical care, can you bill critical care after they've expired? You've provided comfort care, you meet with the family, discuss end of life organ donation. This is not critical care. You would have to bill a discharge code. So Medicare and other payers do allow you to bill a discharge code because you're actually discharging them from the hospital or you're discharging them from care. 99238 is for less than 30 minutes, 99239 is 30 minutes or longer. Pay attention to these two codes. Make sure you document all the time you spend, the time you spend declaring the patient dead. And that time on, anything that you do, any evaluations you have to do, if you're managing organs for donation, if you're documenting in the electronic health records, you're on the floor maybe talking to staff about whatever you need to talk to them about. All that is part of managing that discharge status. Even talking to the family about that would be considered part of the discharge status. So 99238, a lot of times practitioners will bill these codes. They'll bill 99238 because it's less than 30 minutes and not document time. And when I read the discharge summary, I think, gee, I'm sure that that physician spent more than 30 minutes doing all of this work after declaring the patient dead or while they're discharging a patient and not getting paid for it. So make sure you document your total time spent. That's all you have to do at the end of the note. Document everything that you're doing to support your discharge. And one thing to also keep in mind is that critical care is not always critical care unless interventions are not provided. Rounding on a stable patient, most likely a subsequent visit 99231 to 233. You can see patients in the in the emergency department and bill for critical care service if they meet that status of imminent threat. And if you're billing, if you're providing critical care services, let's say in the ED and you move them up to the ICU, then you would combine that time that you're spending, total time with that patient. Now let's say that they were in the emergency department and they were admitted earlier in the day and they didn't require critical care and now they've met maybe had an acute MI or an acute stroke and now they're in the ICU and you're managing their critical care. You can build both services with an E&M code. You'd build a 99291 probably for the first 30 to 74 minutes. You build that E&M service, whether it be an ED visit, an initial hospital care code, and you use modifier 25 to indicate it's significantly separately identifiable. And you would also have a different diagnosis. Even though a different diagnosis is not required based on the definition of modifier 25, you would still have a different diagnosis. Okay, critical care calculating time. All of this is inclusive of critical care time, critical care services, time spent on the unit. You can't combine your APP and physician time, keep that in mind, because that is considered, that's separately billed. You each will bill your own critical care services. Time spent in counseling or discussing patient treatment, if the patient can't participate. If the family has to make treatment decisions, it counts. If you're just updating the family, it doesn't. And this is aggregate time in a single calendar day. You go in at 10 o'clock, spend 15 minutes. You come back at 1 o'clock, spend 20 minutes. You go back at 5 o'clock, now you have to spend 30 minutes. All that time is calculated in for that date of service. It's added up and that's how you select your codes. Researching, reviewing literature, teaching physicians, performing procedures that are not bundled into critical care, do not count as part of that time calculation. So what happens when it continues to the next day? So I've got an example here, patient admitted to the ICU from the ED with hypotension and hypoxia, requiring respiratory and circulatory support. That was an example I had before on 12-1, that was yesterday at 11 30 p.m. And the critical management of the critical care continued until 12-20. So then you come back in today, 12-2 at 1-30, and you provide critical care until 2-10, that's 40 minutes. So on 12-1, you're going to build from 11-30 to 12-20 a.m., 9-9-2-9-1. That's 50 minutes. And then on day two, you have 40 minutes, 9-9-2-9-1 as well. So any continuous time from midnight of the previous day until you're finished with that patient that next morning, that next day is considered included in the previous day's critical care time. And then you would start over. So it's midnight is the turning factor. Okay, let's talk about advanced practice providers. The APPs, we used to call them MPPs, we no longer call them that. Physician assistants, nurse practitioners, clinical nurse specialists, they can manage patient care. One thing to keep in mind, you cannot split bill, as I said earlier, for critical care, but they can provide services under their own MPI, National Provider Identification Number, for critical care, bedside procedures, E&M services, any service not bundled under critical care within the state scope of practice. So if you have APPs who are employed by you, you really need to know what that state scope of practice, or they need to tell you what their state scope of practice is so you know what they can do. So here's an example. Cardiologists, whoops, sorry, go back to the screen. Cardiologists managing a patient in the critical care unit for an MI, patient's worrying, worsening, physician spends 60 minutes managing the patient. So then later that day, the cardiology APP sees the patient, provides critical care for that patient for 40 minutes. So the physician would bill 99291, they met the minimum threshold. The APP would bill 99292, so each would bill their own critical care service. But in the same group, 99291 can be billed only once in the same specialty, and she is a cardiology APP, so that would be the same specialty. Okay, here's another example. We have a PA called urgently to the surgical ICU, patient's in respiratory distress, they're on ECMO, 40 minutes of critical care the PA provides, physician comes in and spends 18 minutes later with that patient. So 99291 would be billed under the PA's name, or 99231, which is the subsequent hospital care code under the physician's name based on documentation. But here's the key, you need to check your RVUs, your work RVUs, because 99291 has 6.30 total work RVUs in 2020, and 85% because for an APP, they receive 85% of the physician fee schedule. So that is 5.36 RVUs, and 99233, which is your highest level E&M, subsequent hospital care, only has 2.95 total RVUs. So 40 minutes for the PA, 18 minutes for the physician, when the physician comes in, you could combine those and that total time and bill it for the complexity of that patient with the subsequent care code, but your advantages might be more so depending on the amount of time spent to bill under the PA with 99291, and this example clearly shows that. So now we have a neural APP performing 40 minutes of critical care, neurocritical care by the physician performs 35 minutes. So how do we bill for that? Whoever goes in first gets 99291. So the APP would bill 99291, the physician would bill 99292 under their own NPI number. Next example. So we have the neurocritical care physician spending 40 minutes and then the APP in the same group 35 minutes later in the day. Now we're going to bill the neurocritical care doctor under 99291 and the APP under 99292. So again, whoever sees that patient first in the same group within that same specialty bills 99291. So let's talk about documentation. This is really important. So what should be documented? First of all, we need to know why the patient is critical. We need a history. What's the medical history? What medications are there on? What labs have you ordered? What are your findings? What about vital signs? We need a well-documented exam every time and any interventions. Now the well-documented exam is what you examine on that patient for that date. Any interventions you make that support the critical care, that's important. A detailed assessment and plan of care, not just continue same regimen. That really doesn't say a lot. And then time documented. Don't use this blanket statement. I spent 30 to 74 minutes in critical care. No. What's your actual time? Now some payers want start and stop time. So your staff should be able to tell you which one want what. But typically for Medicare, they want total duration of time depending on the Medicare contractor and what region of the country you live in. So it's really important that we have a rationale and timing of interventions, the patient's response to treatment as well, all relevant data, a description of everything that you do. So you have to tell a story. So let's look at some documentation. The good, the bad, and I call the ugly. And these are actual notes that I have reviewed. I audit a lot of medical records, critical care records over the years, and I find this routinely consistent. So now we have a patient with type 2 diabetes on metaforum, has cholecystitis, increase in bilirubin, liver function test, which is subsequently improved. She's got some elevated lab levels, abdominal pain, found to have an ST change. You have to support critical care, and I don't see it in the documentation. I like this one. Patient awake, alert, and no oxygen. Chest clear, no murmur. Abdomen soft, extremities are fine. Assessment cholecystitis, waiting for less inflammation, probably a percutaneous to multiple medical problems will follow glucose. The assessment and plan doesn't support critical care. What are those multiple medical problems? What makes that patient critical? Critical care time, 37 minutes, including discussions with whatever, and patient chart review and physical exam. That statement's okay. So we know at least what that included. I love this one. I looked at a note recently, and this is exactly what it said in the assessment. He is calm and talkative, sitting in a chair reading the newspaper. This patient is not critical. I spent 40 minutes providing critical care. Well, if he's sitting in the news, if he is sitting in a chair reading a newspaper, you're going to have a really hard time validating the critical care. Okay, patient remained critically ill due to need for ongoing intensive neuromonitoring, cardiopulmonary monitoring, respiratory monitoring, and support. We need more detail. I spent 102 minutes providing critical care. What was done? What interventions were performed? Detail. Patient's plan discussed in detail with multidisciplinary team on rounds, including bedside nurse. Primary team was made aware of plan. Where's the plan? What's the plan? We don't have a real assessment and plan, and no documentation of any interventions. So we've got a really bad note. This is another note. Alert, awake, some headaches, CT, angiography with 3D view, so show no aneurysm. This was a neurosurgery note. Time spent 40 minutes. Critical care time 31 minutes, no detail. And that was the note, critical care time 31 minutes. That was it. And I know that that's excessive, but these are actual notes that I have actually audited. Here's a woman admitted to the ICU, septic shock. Initial treatment involves intubation, placement of central line, arterial line, mechanical vent, volume resuscitation, antibiotics, norephrine infusion initiated, titrated, arterial pressure management, ventilator titration performed, EKG, arterial blood gas measurement, central venous oxygen saturation determination, etc., etc. Finally, time spent documenting, time spent in critical care management, as well as ICU admission. Total time 119 minutes with 45 minutes devoted to the procedure. This documentation is okay. Patient with acute respiratory distress syndrome, ECMO, blood loss, sepsis, posing an immediate threat of organ system failure. That's really not going to say a lot. Spending 63 minutes evaluating ECMO, respiratory status, and multiple data sources, adjusting clinical plan, and conferring with consultants. And that was it. Unacceptable. Here's a woman admitted to the ICU, unacceptable. Here's a man brought to the emergency department after developing severe shortness of breath. He has severe respiratory distress and acidosis, inserts an arterial and central line, intubates the patient, begins vent management. Patient also has colon cancer of the descending colon, managed by GI, spending 35 minutes. So how do we code this? It does meet the definition of critical care based on the diagnosis. And of course, we want to see more documentation than this. Because we have the time documented, we met the 30-minute threshold. We've got our diagnosis for acute respiratory distress, acidosis, and that's a thing that's really important. Your comorbidities that affect management, which is the colon cancer, is important to document and to code. And it should be your last codes, your comorbidities, but it does support necessity for the complexity of the patient. So we're going to build a critical care, our arterial line, not included in critical care. Central line's not included in critical care, and neither is the emergency intubation. So we're going to build all of these codes separately, and we're going to append modifier 25 that says that the E&M service is significantly separately identifiable on the same date of the procedure or service. So what should documentation always include? Always include the organ system at risk, any diagnostic or therapeutic interventions, critical findings, course of treatment, life-threatening deterioration likelihood, and time spent. And to improve documentation, it's important to have potential actual organ system failure examples in the documentation, any multi-data review. Here's an example that this is a patient with a head injury, loss of consciousness, frequent neuromonitoring, data reviewed. Here's a patient with an acute stroke, hemiplegia, frequent neuromonitoring, imaging, data review, as well as urgent coordination. So things of that nature are really important. So document all diagnoses and comorbidities that exist. Document the acuity, the severity of the diagnosis. If it's acute, if it's chronic, if it's acute on chronic, say it. List all related conditions or underlying causes. Clarify in the documentation any conditions present on admission. That's important for the hospital. And document anything that you're suspecting or trying to rule out so it confirms any certain diagnoses at the time of discharge. So that's the adults. And I'm running severely out of time, so I'm going to talk very fast. Excuse me. Neonatal and pediatric critical care doctors or professionals report these codes based on initial and subsequent from birth up through 28 days based on the patient's age. And the initial hospital care code is only reported once. Now these codes were not added to the telehealth list in the final rule for the pandemic through December 31st, 2021, which we'll talk about in a bit. Subsequent hospital care. These are per day, per diem. It's only reported by one physician in the same group of the same specialty. If you have any other specialty or different group, it can be the same specialty if it's a different group. Managing care on the same date of service would use a critical care codes 9929199292. And if they're readmitted during the same hospital stay, report subsequent critical care for the readmission. If you're in the outpatient setting, emergency room, office, outpatient hospital, you use a time-based 9929199292. And if you're providing you or somebody in your same group in the same specialty sees the patient in the ED and then admits them to inpatient critical care, now you're going to code 99468276, your critical care for feeds, based on their age. And when you transfer a critical care patient from one facility to another, whether it be within your own organization, your own system or not, you would report the time-based critical care codes 9929199292 based on the time you spent, total time. So the question comes up, can you split share a neonate or pediatric intensive care service? Yes. So if you have an APP who works in neonate or pediatric critical care, and you're working in critical care, and you're the physician, and you round the patient later in the day and the APP sees them in the morning, you can split share those visits because they're not time-based, they're per diem. Now, only one provider can bill that E&M for that day, and it's more advantageous to bill under the physician. Only one provider can bill, not both. These are the codes for the neonates and the low birth weight kids, 28 days or are younger. Initial and subsequent, and then our initial hospital care for 28 days or younger of a patient who requires intensive observation, frequent interventions, or other intensive care services 99477. The low birth weight codes are based on grams of weight 99478 to 99480, and these are per day, and these are recovering infants. You might have a patient who's billing, you're billing a neonate one day, and then they're recovering, and now they're a low birth weight, so you would use different codes. Pediatric critical care, these are for kids that are 24 months or younger, and this is during the transport. The critical care 99466 and 994667 are based on time for inter-facility transport for 24 months of age or younger, and then our initial pediatric critical care code, that's for the admission or the first time you see them, that's through two years, 24 months of age, and then 99472 is the subsequent for the 29 days through 24 months, and now we have 99475 and 976 for critical care for children who are two through five years of age. We also have other services, standby services, and if you're standing by, that means you're standing by maybe for a surgery or attendance at delivery. You need to be ready to walk into the OR, so you can't be down on a different floor seeing other patients. You have to be standing by attendance at delivery. We have delivery birthing room resuscitation 99465. We have 99485 for the inter-facility transport for 24 months or younger, and those are time-based along with 99486 for each additional 30 minutes, and these slides tell us what's included in pediatric neonatal critical care. It's the adult critical care plus these services, and you can see that there's quite a few that are bundled in including lumbar punctures, car seat evaluation, CPAPs, transfusions, NG2 placement, etc. In the hospital setting, we use 99221 to 99223 to report the initial hospital care. For Medicare, you append an AI modifier if you are the physician of record, so if you're admitting the patient to the initial hospital, to the hospital for the first time, you would use the AI modifier. Otherwise, you would not. Okay, subsequent hospital care code, so those are your daily visits if the patient's not critical or they're no longer critical, 99231 to 99233. They're based on the key components history exam decision making, and they're based on complexity of the patient. Now, these guidelines are not changing in 2021, not like the E&M for the office or other outpatient. Inpatient consults, Medicare does not allow consultations. You would either bill the initial hospital care or subsequent care. Medicare, some other payers don't allow consultations, but those are payer specific. This is when you're requested to come in and provide your advice. You may initiate care. The report should be put in the shared medical record, so you don't need to send an individual report to that requesting physician. And there must be a request for your advice or opinion. And then our discharge codes, we talked about those earlier, 99238 and 99239, both Medicare and other payers accept these. Based on time, total time that you spend doing everything you need to do to discharge that patient on the floor, including documenting and the EHR. And then modifier 24, the unrelated E&M during the postoperative period, that requires a different diagnosis with your E&M code. We talked about modifier 25, it's for a zero or 10 day global. If it's a 90 day global, it's modifier 57. So let's say you're doing a, you're performing critical care and you're performing a procedure that's not included, like inserting a central line. You would bill for both of those separately and modifier 25 would be appended only to the E&M code. And then modifier 57 is decision for surgery for a major procedure, which has 90 day global. Let's talk about telemedicine really quickly before we end the session today. I'm sorry, I'm going over a bit, but please bear with me. This is important. Medicare, the final rule came out yesterday and I was actually reviewing it last night and early this morning to make sure I had everything up to date. So during the pandemic, critical care services are temporarily allowed for critical care. So there's a temporary addition, your neonate, your pediatric critical care services are not on the list. So those have to be face-to-face by the clinician to bill for. Medicare is waiving copayments. Other payers have waived copayments, don't know if they're going to continue to do that. Some have already pushed back on that. In the final rule that came out yesterday, they are extending the telemedicine services for the COVID pandemic through 12-31-2021. These are the services that allow critical, allow telehealth, a snippet of some that may be important to you, ED visits, your hospital care codes, your discharge codes, your critical care services, initial and subsequent, the intensive and subsequent are no longer being allowed during the pandemic. Modifier 95, Medicare does not use this anymore, but this is a synchronous telemedicine service rendered via real-time. Providers at a different site from the patient. Oh, no, no, Modifier 95 is used by Medicare, sorry, and other payers. Its Modifier GO is only used in Alaska and Hawaii, that's a store and forward technology. If you're in Alaska and Hawaii, it would be Modifier GO appended to your critical care code or your E&M service for that date. Modifier, let's go back, CR, this is for disaster-related, like a hurricane or an earthquake or something disastrous that were to happen. Modifier GT is no longer allowed for Medicare, that's via interactive audio and video, that's only for inpatient hospitals facility coding. You would use Modifier 95. Modifier G0 is for a patient who's had an acute stroke and this began in 2019, January 1st. Now, as far as supervision rules, Medicare does still allow direct supervision. So, if you're the physician of record and you're in another facility or you're somewhere else and you have the video audio capabilities and you're providing telemedicine critical care to that patient, you meet the requirements under the PHE for COVID-19, the extension. One of the reasons why they're allowing the virtual presence during the duration of the PHE for COVID-19 is to limit exposure, but that excludes telephone calls. If you don't have the audio visual, you can't bill for it. So, you have to have a general level of supervision providing supervision. As a teaching physician under the primary care exception rule, the virtual is based on direct supervision. So, you do meet that requirement if you're in a different facility and your resident is in the facility seeing the patient face-to-face and you're providing telemedicine services for that patient that's critical, you meet that requirement. Now, if you're in the same facility, it doesn't meet the definition for telemedicine. It doesn't meet that requirement. That's excluded. You have to be in a different location totally. And I appreciate you hanging in. We're almost done. E&M services for officer outpatient 2021. If you have a post-acute ICU clinic or you're a specialist, you see other patients in the hospital, I've got three slides here to just give you the highlights. E&M services will change in 2021 for officer other outpatient. CPT code 99201 has been deleted. 99202 to 99215 are still accurate. The definitions have changed. No longer will you need the key components history exam medical decision making. It is based on either medical decision making or time. Now in the hospital setting, ER visits, consults, inpatient, subsequent hospital, observation, all those still require the key components history exam medical decision making. Will that change yet next year? We don't know. It's up for discussion. Time is no longer a controlling factor in the office or outpatient clinic or setting unless you're billing by total time. So you have a choice. You either bill by medical decision making or you bill by time. They've changed the RVUs for 2021. They've increased the RVUs for these procedures except the nursing visit 99211. In the proposed rule, the conversion factor they were proposing was $32.26 to the current $36.09. Unfortunately, the final rule came out and the conversion factor is now $32.41. So if you follow your RVUs, your work RVUs, that's what's happened with the conversion factor. So some points to remember. These changes apply only to office or other outpatient 99202 to 99215. Inpatient codes may be revised. We don't know. There's discussions. There's nothing definitive yet. History exam does not necessarily, it has to be documented. It needs to be documented, but it's no longer counted. It has to be medically appropriate according to the definition of the CPT code. But for certification for different diagnostic testing and procedures, you still have to have a history and exam for the payer. All payers must comply because the code descriptions have changed. It has to be medically necessary to perform the service. The lowest level is now 99202. Your assessment and plan of care is very critical for medical decision-making because this is a new medical decision-making table. Two out of three have to be met on this table. And again, this is a three-hour course I give on the new E&M guidelines. You know, in three minutes, I'm not going to be able to give you much, but this is what it looks like so you can see it. It's similar to what we currently use for inpatient and all other E&M services. Using time, you have a choice to use time to determine the levels. And this is what's included. Preparation to see the patient, reviewing notes, reviewing tests, reviewing a history, obtaining a history, performing an exam, counseling, ordering meds, test procedures, referring and communicating with other professionals, health professionals, documenting in the EHR, independently interpreting results of a test that you don't bill for, and care coordination. That's all considered part of the total time spent. And in 2021, this is the time increment. It's no longer typical time. It's now a code range of time. So, in order to get to a 99205, you need 60 to 74 minutes. A 99213 is 20 to 29 minutes. If you're at 28 minutes, you still only code it as 99213. So, sometimes time is more advantageous and sometimes it's not. So, I just wanted to give you a snippet of the questions that may come up as you start thinking about your clinics and what information you might need to document. And again, if you haven't gotten the education for the E&M 2021 and you need it, now is time to do it because we only have about three weeks left until January 1st of 2021. So, I'm going to go ahead and turn this back over to Dr. Mathur. And thank you for attending and for your patience for staying over. Thank you, Debra, for that terrific presentation. I'm sorry we are past our scheduled time, but we will follow up with your questions that were placed in the Q&A area individually. We'll follow up via emails. We have your emails and we'll follow up with them individually. For more questions, please send those to us at support.sccm.org. And we will also have our billing and documentation CAG meeting at the 2021 Annual Congress. The date and time for that will be finalized and broadcasted. Please join the CAG. Once again, thank you to our speaker and the audience for attending. As a reminder, there is no CE associated with this webcast. And that concludes our presentation today.

Billing and Documentation Update 2020

Deborah Greider

critical care billing

medical necessity

coding for critical care

time-based codes

documentation requirements

telemedicine for critical care services

telehealth services

new E&M guidelines

Billing and Documentation