All right, hello, and welcome to today's podcast, Billing and Documentation Update 2021. I'm David Carpenter. I'm the co-chair of the Billing and Documentation category for the Society of Critical Care Medicine. My day job is as a PA at Emory University Hospital and the co-director of quality and patient safety. And I'll be moderating today's webinar. Few housekeeping notes, there's no continuing education credit offered for this webcast. The webcast will be available on demand to registrants about five to seven days after the webcast. Log into mysccm.org and navigate to the My Learning tab. As you can see from the slide, please submit questions using the question button over on the right. It may be collapsed. And type your question in the question box. We'll hold a Q&A at the very end with time permitting. So enter your questions as we go along. And we'll try to answer those that don't get answered separately. The presentation is for educational purposes only. The material presented is intended to represent an approach, view or statement of the presenter that may be helpful to others. The views and opinions are those of the presenters and do not necessarily reflect the opinions or views of SCCM. SCCM does not endorse or recommend any specific test, physician, product, procedure, opinion or other information that may be mentioned. So our speaker today is Debra Greider, she's a coder as well as an auditor. She works for Karen Zucco and Associates. She's authored AMA coding books as well as spoken and consulted on coding nationally. Let me turn it over to Debra. Thank you and welcome everyone. First of all, let's talk about what we're going to talk about today. We're going to give you an overview or a reminder, a refresher on critical care services, coding and documentation, what can be reported separately, what's included. We are going to talk about medical necessity, that's really important in critical care. We're going to talk about patient and management hospital services, which are outside of critical care services, the impacts of the Medicare physician fee schedule final rule and what impact it will have on critical care. There have been quite a few changes. So first we're going to start with medical necessity, coding for adult, and then we will touch on pediatric critical care, but I'm not going to focus on that per se as much as the adult critical care because the pediatric critical care codes and rules have not really changed much. What's included, what can be reported separately. One thing that did change in the CMS physician fee schedule final rule was split share services in critical care. That was one of the issues we're going to cover. We're going to cover E&M services versus critical care services today. So let's get started. This is just a slide that shows you that CPT is copyrighted through the AMA and that they're a registered trademark. So let's talk about medical necessity first and foremost. This is really important. Medical necessity from what CMS has said for years and years and all the other payers follow suit that medical necessity is the overarching criterion when reporting any procedure, E&M service, any service reported and billed for on your claim. So some of the things that you need to ask yourself when you're looking at your documentation, especially with critical care, because critical care is one of the office of the inspector general's hot ticket buttons. And that means that they do like to audit and monitor critical care services. Does the documentation indicate that the assessment services provided support vital system function? Does the documentation validate and support the provider was either at the bedside or immediately available? Now family discussions can be considered part of critical care time if the patient's unable to participate. So let's say that you've got a patient who is on a ventilator and is unresponsive, unable to participate in providing information that's vital to you as a practitioner and you need this information. Discussing that with a family member or caregiver does count towards critical care time. What does not count is giving them an update on the status of the patient. That is not considered part of critical care to determine medical necessity. So what else justifies it? Things like acute cardiac complications, arrest, insufficiency, failure, acute respiratory distress, air embolism, cardiac arrest, cardiogenic shock, fat embolism, malignant hypothermia. These are conditions that do support critical care, traumatic shock, ventricular fibrillation. Now if the patient's on a vent, it doesn't necessarily mean they're critical. If they're stable on a vent, they may not be considered critical. But if you've got a COVID patient on a vent and they're not stable and they're not doing that well, that would be considered, for example, supporting medical necessity. So it's all about the details in your documentation. So explain greatly in detail what you're doing. So let's talk about the critical care codes. The E&M codes, I've updated this for 2022 since the final rule is out. We have the updated RVUs. The ED services, the initial hospital care codes 99221 to 223. Your subsequent hospital care codes and your critical care codes, the 99291, the work RVU is 4.50 in 2022 as well as 99292, your add-on code for each additional 30 minutes is 2.25. So in critical care in 2022, CMS agreed to adopt the CPT language specifically before they created their own language or modified the language. Critical care is now the direct delivery by a physician or other qualified health professional of medical care for a critically ill or critically injured patient. And you'll see that highlighted on the screen. There is a high probability of imminent or life-threatening deterioration in the patient's condition. So the only thing that CMS did was change the language in their rules. And that's publication 100-4, chapter 12. And you'll find the rules for all physician services there. They agreed to adopt CPT language. Critical care involves the high complexity of decision-making to assess, manipulate and support vital system function. And then the examples that are given are things like organ failure, shock, circulatory failure, adrenal, hepatic, metabolic, other central nervous system failure, et cetera. And even though critical care does typically require interpretation of multiple physiologic parameters or applications of advanced technology, it may be provided in life-threatening situations where these elements are not present at the time of critical care. It may be provided on multiple days, even though no changes are made in the treatment, as long as that patient is considered critical. It doesn't have to be provided in a critical care unit or an ICU, but typically it is. And these are the typical terminology, critical care area, coronary care, intensive care, pediatric care, respiratory care, emergency department. Yes, critical care can be provided there as well if necessary. And here are the codes that we have. If it's less than 30 minutes of critical care time, it's an E&M service. So if you provide critical care in the ED for 25 minutes, that's less than 30 minutes, you would bill an ED code. If they're in the hospital, in the inpatient side of the hospital and you're providing critical care and it's your initial hospital visit, depending on documentation, if it's less than 30 minutes, it would be a 99221 to 223 or a subsequent hospital care code is 99221 to 233. 30 to 74 minutes, of course, is 99291 and each additional 30 minutes is 99292. And you can find this information in the CPT code book as well as the, any electronic coding tools that you have. So when should you not use critical care? If you do not meet the definition, if the patient is stable, but critical and you're rounding, it's not necessarily you're managing the critical portion of the patient care. It might not be critical care. For patients in the postoperative global period, if the critical care is related to the surgery, it's not covered as critical care. When you don't exceed or equal 30 minutes and when rounding for a patient not meeting critical care requirements, you would report that as a subsequent hospital care code or if it's related to a surgical procedure and you are the surgeon, it would be considered part of the global package. So it would not be reported separately unless it's outside of that global package and it's unrelated to the reason they're being treated. Services that are included in critical care, providing services at patient bedside, discussing the patient's condition with other practitioners of other members of the patient care team on the unit, reviewing data related to the patient when on the unit, performing procedures that are bundled into payment of critical care, discussion with the family only if it involves obtaining clinically relevant history or information that you need to manage the patient, writing notes in the chart, and that includes entering it into the electronic health record when on the unit. So you have to be on the unit immediately available to that patient to be included in that critical care time. If you're off the unit or you're managing a patient from home and it's not telehealth, which is a different animal in itself, then it would be considered not billable. Things that cannot be included, updating family members, teaching, time spent off the unit, time spent caring for other patients, spent on telephone calls, performing procedures which is separate charges made. So if you're doing a procedure that you can bill for separately, that time is excluded from that critical care time for that date of service. Time spent treating complications, that would be considered part of the global package and not paid for separately. Services included in critical care that you cannot bill separately. And again, this information you can also find in your CPT code book. There is a handout available that you can link to under handouts. And so you can have a copy of the handout as well. Things like interpretation of cardiac output measurement, chest x-rays, pulse oximetry, blood gases, interpretation of physiologic data, gastric intubation, vent management, and peripheral vascular access. Those are all included in that critical care time. The time you spend collecting the blood gases and doing the interpretation is part of that critical care time. You do get paid for that within the critical care time itself. Things that can be billed separately, and this is not all inclusive. This is just a few examples. Swan's gans catheter, endotracheal intubation, a central line, a chest tube, pericardiosynthesis, a TTP. Those are not considered bundled into that time. You can bill for those separately, but you have to carve out your time. So keep the procedure note separate from the visit note for your critical care, even though it's probably in the same part of the EHR, just keep it kind of separate in the note itself and document the total time spent for critical care, and you can say exclusive of the procedure. And that makes it clearer. CPR 92950 is not bundled into critical care. It can be billed for separately. There is no code for trauma resuscitation, so you need to document the time of the critical care exclusive of the CPR if performed on the same date. Now what critical care does require is full attention of the practitioner, whether it be an APN, an advanced practice provider, an APP, or a physician, MD or DO, evaluating, managing, and providing care. So we need to know what's going on with the patient in the documentation. We need to know what assessment you did as far as an exam, the assessment, the conditions you're managing, the comorbidities you're managing, and what's your plan of care. And it needs to be enough detail to validate critical care. During the time you're providing critical care, you cannot provide services to any other patient. You have to give full attention to that critically ill patient and immediately available to that patient. And time is counted for your care that you provide at the patient's bedside or elsewhere on the floor or unit that you're managing the problem for that patient, that critical care period of time. And you can count ordering, reviewing lab results, discussing the patient with other physicians, other medical staff, even when it does not occur at the bedside. But it has to be full attention to that patient. Time spent off the unit or floor or in the office or at home may not be reported as critical care time because you're not immediately available to the patient. That's considered pre and post service work bundled into that E&M service. So in 2022, the Medicare physician fee schedule came out. They emphasized that 99291, which is the first 30 to 74 minutes, can only be used once per day per group. Now if you have an advanced practice provider who is part of your group, they are part of your specialty. So that includes them, even if the time spent by the practitioner is not continuous. And then once you meet that 74 minute threshold and you move into 75 minutes, each additional 30 minutes is 99292. And this just changed and we'll talk a little bit more about that later on. So here's a few examples. You're called to the emergency room by emergently to the patient's bedside. They're in critical care. They're hypovolemic, hypoxic, or they have an organ system at risk. You immediately intervene and spend 30 minutes of critical care time. That's 99291. You document that in detail, bill the 99291. Now here's an example of the patient who's 45 years old, had a hysterectomy. They had cardiac arrest associated with the pulmonary embolus. And the physician spent an hour managing the critical portion of care. That critical care is unrelated to the surgery. And if it's supported by documentation, you could bill for that critical care service if you're not the surgeon who did the hysterectomy, or subsequent hospital care, or non-billable if postoperative. So if it's part of the postoperative care, which if they had a cardiac arrest and a pulmonary embolus following a hysterectomy, that would be considered unrelated to the surgery itself. Now we have a patient in the ICU, stable and moving towards discharge to the next level of care. No intervention or organ system issues remain. This would be subsequent hospital care. Or if you are the surgeon who did the procedure, it's part of the global package and not billable separately. So again, full attention of the physician has to be realized. Now concurrent care by more than one physician, and usually it's different specialties, you have to meet the critical care requirements. So let's say you have a patient who has congestive heart failure, they've had a heart attack, and now they're in acute respiratory distress and pulmonology is involved. So you've got cardiology and pulmonology both managing critical portions of the patient care. You can provide concurrent care as long as the providers, it's medically necessary. Care pays for non-duplicative medically necessary critical care services. So you can't duplicate it from the same group or from different group practices to the same patient. So documentation has to support that the critical care service is medically necessary by each physician. So pulmonology is going to document their acute respiratory distress and cardiology is going to document well as far as the heart conditions. So each physician will report their own services because they are of different specialties. And a physician specialty means is the self-designated primary specialty by which the physician bills. So the APP is considered to be in the same specialty and subspecialty as the physician that could be a nurse practitioner or PA, CNS with whom he or she is working, even though they have their own NPI number and they have their own specialty code. They're considered to be the same specialty in this instance. They may provide concurrent follow-up care subsequent to another practitioner's critical care visit. They might be performing continuous staff coverage or follow-up care on the same date. And the time can be aggregated. That means the time can be added together now, which is different from 2021. So here's an example. Dr. A sees a critically ill patient for 40 minutes. Later in the day, the PA comes in and sees the patient for 34 minutes. Now we have 74 minutes, which is the maximum threshold at 30 to 74 minutes for 99291. Only 99291 would be reported. You would not report 99292 for the PA as you would currently today. In 2022, that time is aggregated together and you bill 99291. If they are a different specialty, and I'm going to talk about the split shared in a bit, so it kind of ties together with the split shared. If you're a different specialty and you meet the definition of critical care, like with pulmonology and cardiology, it may require the care of more than one physician. More than one specialty might be medically necessary and it can't be duplicative. So it has to be non-duplicative critical care services. So you've got the acute MI for 66 minutes and the pulmonologist managing a pulmonary embolism for 45 minutes. The cardiologist and the pulmonologist would each report 99291 for their time spent, document their time in detail, as well as the detail of the service they provided. Each would report their separately. Rounding is not always considered critical care unless interventions are being provided to manage the critical care portion. If they're stable, they're most likely a subsequent visit 99231 to 233, depending on documentation. Okay, other services on the same day. E&M services provided before critical care at a time when the patient did not require critical care. This changed in 2022. So let's say that you've got a patient who comes in through the ER, they're admitted, let's say by the emergency department physician, you're the pulmonologist, you're being called in to manage the patient's shortness of breath and their respiratory condition. They're stable, you've ordered tests. Later in the day, they worsen and now they're critical. If it's medically necessary, and you are providing the initial hospital care initially and then the critical care services later on, you can report the critical care service with modifier 25 on the claim and get paid for both. However, if they were critical previous, they were critical at this moment, and later in the day, they're no longer critical. You cannot get paid separately for that E&M service for that date of service. It has to be prior to. So one of the things that kind of changed and didn't change for under the current rules are that if you have an initial critical care service you can bill critical care after and that's explicitly stated. This is a little bit of change because in the original, in the CPT code it wasn't explicitly changed. The one caveat I will say is that some MACs, a very few of them were getting other E&M services paid after critical care and that's explicitly prohibited in the new rules. Could you advance the slide, please? So when critical care continues into the next day, if, as long as the critical care is continuous, you can accrue that time and report it on the pre-midnight date. But the minute you stop and do some other thing, then you start accruing the time on the date where the time is accruing. For example, if you started seeing a patient at 11.40 and continued to see the patient until 1.40 in the morning, you would accrue two hours of critical care time on the day that you started seeing them. If you saw the patient from 11.40 at night till, you know, 00.40 and then stopped and then came back half an hour later and accrued more time, you would report the 99291 for an hour on the first day and then whatever time you accrued on the next day. So can you, one of the questions you get asked, if the patient is brain dead, can you bill critical care? And the answer is no. You basically, and usually the way it works, at least around where I am, you can bill discharge on the date they die and then the organ procurement organization usually takes over and there's no more billing. All right, so what David was saying is that for brain dead patients, the procurement team typically takes over. You can bill a discharge and the discharge codes 99238 and 239 are time-based. So you need to document total time spent and that would be total time spent examining the patient, declaring them brain dead or declaring their death, documenting in the EHR, closing out everything on the unit would all be considered part of that time spent for critical care or for the discharge, sorry. Okay, advanced practice providers, who are they? Physician assistants, PAs, nurse practitioners, NPs, clinical nurse specialists. They can manage care so they are considered advanced practice providers. So beginning January 1st, split shared, this is new. Prior to January 1st, so as of today, split shared services in critical care are not allowed by the advanced practitioner and the physicians. Beginning January 1st, CMS will allow split shared visits for critical care. And what the definition of a split shared visit is a service performed in part by both a physician and an advanced practice provider who in the same group, same specialty, in a facility setting and that's an institutional setting in which payment for services, supplies, are furnished incident to a physician or practitioner where it's prohibited. So in the office setting, an incident two services are allowed under certain circumstances, but incident two is not allowed in the hospital or facility setting, but split shared service will now be allowed for both new and established patients for critical care and for skilled nursing facility E&M visits. So what does that mean? That means that a visit can be billed by the practitioner or the advanced practice provider. And it's one who provides a substantial portion of the visit and in critical care, that means more than half the time. So more than half the total time would be who bills for it. So even if the, let's say the PA goes in and sees a patient in the morning and the physician rounds in the afternoon, that time is aggregated. They're the same specialty, same group, that time is aggregated, added together for the total critical care time. And for critical care, it's the person who bills more than half the total time since critical care is time-based. Now, when we get to the initial hospital care, the ED visits, the subsequent hospital care, it's a little bit different. And we'll talk about that when we get there. But for critical care, it's whoever provides more than 50% or half the total time. Now, one of the advantages of physician billing is of course, 100% for Medicare, the physician fee schedule is allowed, whereas for the APP, it's 80%. So here's an example. Cardiologist managing the patient 40 minutes. Later in the day, the APP, who's the cardiology APP, provides critical care to the same patient for 25 minutes. That's a total of 65 minutes. That meets the threshold of critical care 99291, 30 to 74 minutes. So the physician will do the billing because they spent more than half the time, the substantial time for critical care. They'll bill the 99291 and the APP would not bill anything. So all the time is aggregated and billed under the physician's NPI number. Now again, today, we don't do it this way, but January 1, 2022, we will. So to qualify for a split shared visit, the physician and the APP have to be in the same group, same specialty, jointly furnishing work related to the patient encounter. They must see the patient at different times, not together. So if they're together managing the patient, only one person will bill, and it's typically the physician who will bill. If they're in different groups, different specialties, they bill their own services independently. So if you're in a multi-specialty group and you have cardiology and pulmonology, you've got the cardiology APP and the pulmonology APP, they are separate, they're different because the APPs are not in the same group. Even though they might be in the same organizational group, they're not in the same specialty group. Time spent by two practitioners in the same specialty who spend time jointly seeing the patient, examining, discussing patient, they can count only the time once. And the patient who has the most substantial portion of the visit bills. And again, physician payment is 100%. And I said 80% for APPs, but it's 85. So there's a 15% loss of revenue if the APP bills versus the physician. Documentation, this is important. Documentation in the medical record must identify who performed the visit. Each practitioner who performed the visit and the practitioner who provided the substantial portion of the visit signs the visit and dates it in the medical record. Each practitioner needs to document their services provided, including time, even if let's say the MD is the one billing. So if the PA is documenting services, seeing the patient managing care in the afternoon, physician saw the patient in the morning, each will document in detail, a good note with total time spent. The physicians spent 40, let's say 40 minutes, whereas the PA spent 25 minutes. So the physician will actually sign the note and date it, even though we know both providers participated. So we have a new modifier that has to be used. It's called the FS, split or shared E&M service. So each time a hospital E&M visit is performed split shared, whether it's critical care or not critical care. So the FS modifier, the two big things with the way we normally do things are, you just need to make sure that when you have, when you're doing shared split billing, that you put the FS modifier in. That's the big thing. The FT modifier is a new modifier where you're doing an unrelated E&M visit during the postoperative period. And answering the questions in the question section, there's a lot of confusion. Fundamentally, it's basically from a critical care standpoint, it's unchanged. It's more a tracking modifier to see how much of this is actually going on. So if you're performing an unrelated E&M service during the global surgical period, you just need to put the FT model. And for example, if a patient has, some kind of neurosurgery, comes to the ICU hypotensive and intubated, you know, any manipulation of the vent, hemodynamic manipulation, resuscitation, all that's critical care, as long as it's performed by a different specialty. Similarly, if you have a post-op surgical patient that comes out of surgery in sepsis and you resuscitate them, or they develop sepsis during their hospital stay for the global surgery period, all of that is paid. So mostly this modifier, originally the rule proposed was that they weren't gonna pay any critical care during the global period. And a number of people, including SCCM, kind of informed them that that's not really how critical care works. And so, unfortunately, they didn't do this. So critical care is reimbursed during the global period. The, there we go. So when is it not, so, and this is actually where, you know, if the patient becomes hypertensive after abdominal surgery during the hemorrhage of a surgical site, and this kind of gets a little iffy, but, you know, depending, you know, the decision to take the patient back to surgery, but if the patient needs resuscitation by the critical care service, and it's provided by a different team, I would think this would be actually considered allowable. If the surgeon manages a patient during the postoperative period, then manage their fluid and nutritional needs, that wouldn't be payable. If they manage the patient postoperatively in the surgical ICU, and this is kind of an observation, for example, if you have somebody an observer and the surgeon is managing it, then there's no critical care there either. And a few of the mostly cardiovascular, cardiovascular surgical codes actually have critical care devalued in the code, and that's where this all came from. So if you're a trauma specialist, and intensive as a hospital, you need to know, is the encounter unrelated to the global postoperative services? Are both physicians reporting critical care for the same clinical problem? And this happens frequently in CV ICU, where, for example, the anesthesia critical care may be managing the vent and the hemodynamics, and for example, the cardiovascular team is managing like an LVAD or an ECMO pump. And so generally you need to structure your diagnosis differently, so you shouldn't be reporting the exact same diagnosis codes in the exact same order, if it's two different groups. And then the payers usually want to see, demonstrate medical necessity in the documentation. So what should be documented? And this is actually one of the things we run into a lot. The CPT requires a chief complaint for every patient, so if you're using an EMR, make sure that you have a place for the chief complaint to go and make sure it gets filled out. The history, well-documented exam, and then interventions that make this a critical care encounter, and then a detailed assessment and plan of care. And then you need to document time. And usually, so one of the things that this is a, you know, I know Deb's a coder, but this is actually where the coders and the physicians or the providers kind of differ. I actually urge people not to document like specific times, like I took care of this patient for like 1535 to 1635. In the time of EMR, it's very easy to demonstrate that you did something else. You know, you put an order in, you did something else, you clicked into a chart during that time, and CMS knows this. And so what I would encourage you to do is say this is how much time I spent, and make sure your documentation backs up that you spent that much time. So here's just a couple examples of, you know, kind of what is good or poor documentation. This example, I was putting some examples together of things I've seen. I do a lot of audits for critical care. This is a 75-year-old patient, type 2 diabetes, has cholecystitis. She's in the ICU, and this is all I had with total time spent. What findings support critical care, or why is she critical? That's a piece that we need. We've got awake, alert, no oxygen, chest clear, so I'm looking at the exam, and then the assessment. And the assessment and plan don't really support critical care. So this is just an example of documentation, what pieces are missing that could help support medical necessity for critical care. And it's not that this patient is not critical, this patient was critical, but the documentation didn't support it. So when you mention multiple medical problems, it's really important that you document what are those multiple medical problems? What are those comorbidities that help support the patient, support medical necessity for critical care? So then the documentation at the end says critical care time, 37 minutes, including discussion with APP and patient. That's all appropriate for the physical exam and chart review. So that would support the 99291 from a time-based standpoint, but then again, documentation could be a little bit tighter. And this one, I love this one. I always laugh at this because it's really a true fact. This was actually a critical care doctor that I was shadowing, and this is what he put in his documentation in the assessment. Patient calm and talkative, sitting in a chair reading the newspaper. I don't think this is gonna support critical care if a payer looks at the documentation. He was in there 40 minutes, but what we need to know is if they're sitting in a chair reading the newspaper, why are they critical? What was done during that time? What interventions were performed? So the devil is in the details. We need the details. And then the next one, patient remains critically ill due to need for ongoing intensive neuromonitoring, cardiopulmonary monitoring, respiratory monitoring and support. Not enough detail provided. I spent 102 minutes providing critical care. What was done? What interventions were performed? What was the detail? Patient plan discussed in detail with multiple disciplinary team on rounds, including the bedside nurse. Primary team was made aware of the plan. What plan? Again, we need the plan documented in detail or know where it is. We don't have really a chief complaint. Why are they critical? There's no assessment and plan, no documentation of interventions provided. And they billed 99291 and 99292. And the one thing that triggered me on this one, so we really didn't know if it was rounding or if it was critical care. So that's one of the areas that could be improved. And I just pulled out some really bad ones. Here's one where the patient is in septic shock that supports medical necessity. Treatment, intubation, placement of central line, arterial line, receives mechanical vent, volume resuscitation, antibiotics. So there is detail here. Total time spent 119 minutes, 45 minutes devoted to the procedures. So we could bill the critical care time appropriately with this documentation. This is another example, acute respiratory distress on ECMO, blood loss, sepsis, posing immediate threat of organ system failure. This was the note. I spent 63 minutes evaluating ECMO respiratory status, multiple data sources, adjusting clinical plan and conferring with consultants. That's not going to cut it with a payer. They want the detail. What consultants, what clinical plan, what are those data sources? Give me that in detail in the documentation. Now with electronic health records, it's easy to pull that information in and update it and sign off on it so it does support medical necessity. Here's a patient short of breath, emergency department admitted for critical care with severe respiratory distress, acidosis. The physician inserts an arterial and central line, intubates, begins vent management. Patient also has primary colon cancer of the descending colon managed by GI. Critical care time, 35 minutes. Is that a good note? Need some more detail. But with this one, we're gonna build a 99291 for the first 30 to 74 minutes. 35 minutes was spent. Intubation, that management is included in the critical care time so we would not carve that out. And then of course our diagnosis codes are gonna support medical necessity. And we are going to code the malignant neoplasm. It is a comorbidity that affects management of care. So then we're gonna code the arterial line, the central line, the intubation, the emergency intubation. That's all going back here. That's all part of that critical care time. So what should we always document? First of all, we have to have a chief complaint. Why are they critical? Always. The organ system at risk should always be documented. Was it a diagnostic or a therapeutic intervention? If they were, what was performed? What procedures? Any critical findings, lab tests, imaging, course of treatment, plan of care, likelihood of life-threatening deterioration without an intervention, it would be helpful to have that information. Time spent on adult critical care, so total time spent. So at a minimum, that's what we need. And provide specific examples of potential or actual organ system failure. Documentation of multiple data review, the intense monitoring, complex decision making. So here's an example. Patient with head injury, loss of conscience, requires frequent neurologic monitoring and data review. Here's another one. Patient with acute stroke and hemiplegia requiring frequent neurologic monitoring, imaging, and data review, as well as urgent coordination with multiple specialists. So that kind of gives us a lot of insight as to why this patient is critical. So just some tips. Document and code all diagnoses and comorbidities that affect patient care. Document acuity, the severity of all diagnoses. That's really important. List all conditions related to the underlying cause, if known. Clarify in the documentation any conditions present on admission. Document rule-outs, suspected. Even though we don't code those, we need to document what you're thinking along with the signs and symptoms to bill for those. And then confirm any uncertain diagnoses at time of discharge. Total critical care time needs to be documented in the medical record. Any procedures that are carved out need to be carved out of that time. And medical necessity has to be evident that it is critical care. So I'm just gonna briefly touch on the Pediatric Critical Care Transport Codes. And then the work RVs are included in the handout. These are based on age of the patient, 24 months of age or younger. And these are either face-to-face or non-face-to-face for an inter-facility transport from one location to another, one facility to another. Services that are included and not reported separately are things like pulse ox, interpretation of cardiac output, pulse oximetry, blood gases, intubation, vent management. Those are all considered included in the Pediatric Critical Care Transport. And the face-to-face codes are 99466 and 467. And those are only reported 24 months or younger. And the face-to-face time begins when you as a physician accepts responsibility and ends when you hand that patient off to the other facility providing care, that will be providing care. And it's only the direct face-to-face contact. And these services are time-based. And then the non-face-to-face 99485 and 86, that's the inter-facility Pediatric Critical Care Transport. And that includes two-way communication between the control physician and the transport team. I don't know if many of you have this option available in your facilities, trauma centers typically do. Only for patients 24 months or younger who are critically ill. And that begins the non-face-to-face time when the control physician has contact with the transport team. And these are time-based codes as well. Now the neonate and pediatric critical care codes, they're based on age of the patient. And the initial hospital care is reported once. And we're gonna look at these codes here really quick. Subsequent hospital care are per day. So the initial is when they're admitted or the initial visit for critical care, the subsequent are per diem. And it can be reported only by one physician specialty in the same group, no matter how many manage the patient within that same specialty on that same date. If another physician of a different specialty is called in to manage the patient, as well as the physician of record, the critical care physician, they would use 99291 and 99292, the adult critical care codes based on time. So you've got, let's say pulmonology is managing the critical care neonate, and then cardiology is called in to manage a critical portion of the visit, they would bill the 291 and 292. Split-shared and pediatric critical care is allowed. And it's the person who provides a substantive portion of the visit. They bill for the split-shared visit. So for non-critical care, it's the substantial portion of the visit. And the critical care for PEDS is considered per diem. So whoever spent the most, has the most documentation, and spends the most time with the patient would be realized for that critical care visit, billing for that visit. 99468, 99469, these are for 28 days of age or younger. And the initial is 6869 is subsequent. The initial 99477 is for 28 days or younger who require frequent intervention, other intensive care services. The subsequent intensive care for neonates that have current body weights of less than 15 grams and 15 to 2,500 and 2,501 to 5,000 or 9947880. And then of course our pediatric critical care 29 through 24 months of age. And then our initial and subsequent 475 and 764 are two through five years of age. And the guidelines have not changed for these. And then we have other critical care services, our standby. When you have standby service, that means that that physician must be available immediately. Typically it's for things like high-risk deliveries that you might be standing by, attendance at delivery, supervision for the inter-facility transport. And that's 24 months of age or younger. And then those are time-based 99485 and 86. So for pediatric critical care, all of the adult critical care services are included and bundled into pediatric critical care as you can see here. Plus they've added into critical care the peripheral vascular catheterization, the central vessel catheterization, vascular procedure punctures, the endotracheal intubation, bedside pulmonary function tests. Those are all included bundled into pediatric critical care. No changes from last year on that. And then again, these are also bundled into critical care. Things like car seat evaluation, nasogastric tube placement, bladder catheter, lumbar puncture, those are all included. So those are the critical care for PEDS. And again, I just went through those briefly because there are no changes. Now our E&M codes for 2022, the initial hospital care, subsequent hospital care codes, our consultations, there are no changes. The history exam, medical decision-making must be documented, those three key components. The initial hospital care codes are used for the initial visit. It's not necessarily the admitting physician. It can be the admitting physician. If you are the admitting physician, you use the modifier AI for physician of record. Medicare does not allow consults. So you would have to bill the 221 to 223 for the initial hospital care. And just to share that the initial hospital care code requires at a minimum, a detailed history and exam for 99221. If you don't meet that requirement, that threshold, you are at subsequent hospital care regardless if it's your initial visit. Your subsequent hospital care codes 231 to 233. These are daily visits when it's not included in the global surgical package and they're not considered critical. And our consultation codes, Medicare, of course, does not allow consults. We have to use 221 to 223 for the initial or 99231 to 233 for subsequent. And a consult is a request for advice or opinion. You may initiate treatment. Your record is shared, so you don't need to send a letter back to the requesting physician since you're in the inpatient setting. And then the 238 to 239, those are discharge codes. Those are time-based. For the first 30 minutes is 99238. Each additional 30 minutes, 99239. Okay, let's talk about split-shared. Split-shared for non-critical. So these are your subsequent, your initial hospital care, your ED visits. Whoever provides a substantive portion of the visit, and that's more than half of the total time spent by the physician or APP or for non-critical care services, the history exam or medical decision-making can be considered a substantive portion to bill in 2022. So if you've got most of your documentation, let's say the PA goes in and does a history and exam, formulates an assessment and plan. The physician comes behind that APP and documents that they agree with the plan of care and sign off on it. Well, it's obvious in the documentation that the substantive portion of the visit is the APPs. So it would be billed under the APP. But if you're using time, which you can use total time to substantiate that portion, whoever spends the most time, at least 50% of that time can bill for that subsequent or initial hospital care code. And I know that can get confusing because typically for your non-critical care time, you don't document time because it's based on the history exam decision-making. So whoever does either more than half the total time or the substantive portion of the history exam or decision-making bills are split shared using that FS modifier. In 2023, it's going to be based on time, and they are going to be changing the guidelines for these hospital E&M services. We don't know to what yet, but keep in mind that they are planning on making that change in 2023. Also keep in mind only one practitioner can bill split shared with modifier FS. And again, the physician who bills the visit has to sign off and date it. Both practitioners need to be listed. Okay, and you can see here on the screen the split shared history exam for inpatient hospital observation, emergency department, outpatient. For critical care, it's time only. In 2023, the definition will be more than half the total time. Okay, some takeaways. If critical care crosses midnight, it's accrued until the service is no longer continuous. So if you are with the patient from 11 to 1.30 and then you go to another patient for a few hours and then return to the first patient for an hour, the first time you see them from 11 to 1.30 would be 99291 plus three units because you spent 90 minutes with that patient or more than 74 minutes. And then let's see, 11 to 1.30. My brain has gone off here. That's two and a half hours. So it would be 99291 to 292. You leave the patient. Now keep in mind, you crossed midnight. So now you're going back to see them again and manage the critical care. You start over again with a 99291. If you're managing multiple conditions for the same patient concurrently, you can now claim critical care providing their medical necessity and non-duplicative. Practitioners in the same group can aggregate their time to cross the threshold of 99291. Again, you have to meet that 74-minute threshold. And I believe back in the 80s, we had to do that. And then they changed the rules. Now it's kind of going backwards. Critical care is eligible for split shared with the FS modifier and the provider who spends more than 50% of the time bills for it in critical care, 99291, 99292. For pediatric critical care and non-critical care, it's whoever performed the substantive portion of the visit or spent the most time, either or. If the patient has a same-day E&M visit and critical care and both services are medically necessary, no duplicative elements, both may be billed. And that means that you have to have an E&M visit, let's say an initial hospital care or subsequent hospital care, then they become critical. You would use a modifier 25 to identify that it is significantly separately identifiable. And that critical care can be paid in addition to the global surgical period, the procedure, as long as it's unrelated to the procedure. And CMS has defined that documentation is necessary to get credit for critical care time. We don't wanna use a range or threshold met. And I've seen that where total time, 30 to 74 minutes. You don't do that. You document the exact time you spent to get credit for critical care. There has to be evidence the care was medically necessary and the role that each practitioner played is required. So those are some of the takeaways for some of the changes made for 2022 for critical care. Again, split share does not go into effect for a couple more weeks until January 1. So the rules that we have today are applicable until we change on January 1, 2022. So I will turn this back over to David. Thank you. Thanks. We're right on time, but we kind of intentionally built about 10 minutes. So if anybody needs to leave, please, but we'll go to about 10 after. Deb, specifically, I apparently confused people about the FS and FT codes. Can you go over that again? And specifically, we have a question. Is the FT modifier only for the surgeon to bill for that's unrelated, or does anybody in the ICU need to use that code? And then we had a related question of if you're using the 24 modifier, do you also have to use the FT modifier? Okay. You know, that's a good question. And we haven't gotten a lot of clarity from CMS about that. I would say that if it's during the global surgical period and you're providing services in the hospital, the FT modifier is the modifier you should use if you're the surgeon. If you are, let's say, the intensivist and it's unrelated to the global period, well, again, let me back up a minute. I would say that you could use the FT modifier as well, because it doesn't specify that you're the surgeon. The FT modifier just says that it is a service provided. It's a service provided, an E&M service provided during the global period that's unrelated to the surgery. So you should be using the FT modifier. Now, CMS has not come out with an FAQ, to my knowledge, that's talked about FT versus modifier 24. Because modifier 24 says it's an unrelated E&M during the post-op period, it says the same thing as the FT modifier. For your commercial payers, this is just for Medicare, the FT modifier. Your commercial payers have to make a decision whether they want 24 or FT, unless, David, you've heard anything different. No, I mean, there's very little out there on this. Right. It seems like mostly it's gonna only apply to critical care. So if you have an unrelated E&M for not critical care, what I got from the kind of the guidance that they put out was that, you know, the original proposal was to not pay any critical care during the global period. Right, right, it was. Whoa, whoa, whoa, this is actually not how critical care works in the non-Marcus Welby universe. And so then they're like, oh, well, we don't actually understand how much critical care is actually, you know, provided in the post-op period. So I think this is their way of figuring that out. So it's- Right, right. So they can monitor it and determine, do we pay for critical care outside of the global period routinely or not, or how do we make changes? Right. That's what I'm getting from it. But if it's not critical care, I would use a 24. Right. That's just my best guess right now until we get some more clarity from CMS on that. Yeah. And let me, so let me kind of answer a bunch of questions about time. Because one, when I do consulting, I find this is where it gets messed up a lot. You know, for example, there was a question, well, can I co-sign or, you know, co-sign the APP note and get 100%? That's never been the, you know, you have to do the work. Right. And there's a question, if the MD rendered 30 minutes earlier in the day and the APP renders 60 minutes later on, can we build this as split shared and just build the 99291 for the MD? And so this gets actually super complicated. In the old, you know, prior to January 1st, I would say probably you could get away with that. In the new rules, you pretty much clearly can't. Right. That's true. You can today because payers will accept it, but tomorrow you won't be able to. So January 1st, if you look, the MD did not do the majority of the 99291 or any of the 99292. So all of that, you know, and actually in our system, the way our system works, all of that would have been built under the APP anyway, because the way we do it is we actually look at who did the bulk of the work. Actually, the way we would probably do that, to be honest, is build the 99291 under the APP and the 99292 under the MD, because the 30 minutes would qualify for the bulk of a 99292. But, and there's actually an interesting question, which I hadn't really considered, is could you, you know, let's say you had an MD bill, 60 minutes, and an APP bill, 30 minutes, and then the next day, you know, the APP bill is 60 minutes and the MD bill is 30. Could you choose to do one of those as shared split and the other as not shared split? And I don't have a good answer. I think that the MACs are going to probably come out and say, you got to choose one or the other. Because otherwise, you can't get into the system, right? Right, and I don't think they've addressed that yet. They haven't addressed whether or not you could bill, you could choose not to bill split shared. Well, so they have. I mean, at least Medicare, when their guidance came out and said, this year, you can either bill things under each individual's MPI. Right, right, they did. So they did address it, but they didn't address, and I think the specific is, they did 35 minutes and say, 40 minutes on one patient. And then on the other patient, it was flipped around. And so, you know, what you would potentially do is allow, you know, one way you could, you know, if you bill those under split share, all of it would go into the APP. One of the other ways, some of it would go under the physician and you get reimbursed 100%. So I think that's to be determined. Yeah, that's getting into the gray zone where we're not really sure how the MACs are gonna look at that. Yeah, let me see here. And hopefully we'll have some more answers from the MACs, which are the Medicare Administrative Contractors after the first of the year. Usually they wait until these rules are enacted and they run into problems before they start addressing the questions. Yeah, and then somebody asked, innovation is not bundled. It's not including critical care. Vent management, I think is what, there's a question about something about what was bundled in critical care. So, and there's a last question on brain dead, like optimizing brain dead patients. Including better management. My understanding, and it's a weird world out there. Once the patient's been declared dead, you can no longer bill on them. My also understanding is if you work on optimizing the brain patients for the procurement team, the OPO should be paying you for that work. Not, because the OPO gets paid for the organ and the procurement. But that's how it works in our, once the patient's declared brain dead and they're gonna be an organ donor, the OPO nurse is actually taking care of the patient. The OPO's medical director does all the guidance stuff. We actually have nothing to do with it. We continue to supply drugs because they don't have all the drugs necessarily. But other than that, we don't really do anything with them. Right, but you do bill that discharge. Yeah, or if they're critical care, or you could, the other way to do it is until you've made the decision, until they're known to be brain dead, you can bill critical care because you're a blind patient. So a lot of times, you actually bill critical care right up until they're brain dead and then you don't. So then you can't bill the discharge because that would be another E&M after critical care. So it's usually, usually- One or the other. If you just bill the critical care in that case. Yeah, I agree. You still have to pay the discharge summary, but you know, that's that. All right, well, thank you, everybody. And everybody take care.

billing updates

documentation updates

critical care services

medical necessity

documentation requirements

split/shared services

FS modifier

FT modifier

pediatric critical care

detailed documentation

Billing and Documentation