Hello and welcome to today's webcast on Billing and Documentation Update 2022. My name is Piyush Mathur and I am the co-chair of the 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 credit associated with this educational program. A recording of this webcast will be available in five to seven business days. You could log in to mysccm.org and navigate to the My Learning tab to access this recording. For audience participation to submit questions throughout, type your questions into the question box on your control panel. The Q&A panel will be held at the very end so please be sure to enter your questions as we go along. Please note the disclaimer content over here stating that this is for educational purposes only. And with that I would like to introduce our speaker for the day. It's Debra Greider. Debra is a senior consultant with Karen Zipko and Associates and an 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 Debra. Debra, please take it away. Welcome everyone. We're going to start talking about the learning objectives for today. We're going to look at medical necessity and how it drives supporting critical care services, how evaluation and management services in the hospital versus adult critical care services differ, and discuss how documentation impacts reimbursement for hospital and critical care visits, and talk about split shared visits with your APPs and critical care and hospital services with the required documentation and modifiers. So let's go ahead and get started. There is a U.S. legal doctrine that's related to medical necessity activities and how it must be justified. Medical necessity for a service must be reasonable, necessary, medically appropriate based on clinical standards and other factors such as credible scientific evidence published in peer-reviewed medical literature recognized by the medical community and specialty society recommendations. CMS has always said that medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of that CPT code, and it would not be medically necessary or appropriate to bill a higher level of an evaluation and management service or a procedure when a lower level of service is warranted. And that is something that CMS has said for many years back in the late 90s. So in essence, medical necessity means that a health care service provided by a physician or other qualified health care practitioner, which would be your PAs, NPs, CNSs, your APPs, must exercise prudent clinical judgment for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or symptoms. Medical necessity is not justified by a point system. It's based on clinical judgment, standard of practice, the reason the patient is there, the reason for their visit, the reason for being in critical care, the reason for hospitalization, and that comes with the chief complaint. Any acute onsets or exacerbations of medical conditions or injuries, the patient's stability or acuity, looking at multiple medical comorbidities, which should be documented in the medical record, and management of that patient on that specific date of service. So critical care services both encompass treatment of vital organ failure or prevention of further life-threatening deterioration of the patient's condition. So therefore, although critical care may be delivered in a moment of crisis or upon being called to the patient's bedside emergently, this is not a requirement providing critical care service. The treatment and management of the patient's condition, while not necessarily emergent, shall be based on the threat of imminent deterioration. The patient shall be critically ill or injured at the time of the physician or APP's visit. So one example, what about the patients that come that you're managing on a ventilator on a daily basis in the ICU? Well, daily management of a patient on a ventilator does not always meet the criteria for critical care, unless the critical care is separately identifiable from the management of the bed. So one example is you have a patient's partial pressure of oxygen dropping, requiring your immediate attention to evaluate the problem and make treatment adjustments. The patient has a mucus plug potentially compromising the airway. You assess the problem urgently, remove the plug, and make it appropriate. You make appropriate treatment adjustments. Those would be two examples of where critical care would be supported, as long as it's documented correctly. So other conditions that justify medical necessity for critical care include acute cardiac complications, arrest, insufficiency, failure, etc. during or following a procedure, an acute respiratory distress, anaphylactic shock, cardiac arrest, fat embolism, malignant hypothermia or hyperprexia due to anesthesia, respiratory arrest, shock, septic shock, traumatic shock, ventricular fibrillation. These are all examples. So now let's talk about critical care services for adults 99291 and 99292. Let's look at the definition of critical care for 99291 to 99292. Critical care is a direct delivery by a physician or a qualified other qualified health care professional and that would be your advanced practice providers. And CPT calls them QHPs, whereas we call them in the clinical setting advanced practice providers. For medical care for a critically ill or critically injured patient and a critical illness or injury acutely impairs one or more vital organ systems and there is a high probability of imminent or life-threatening deterioration in the patient's condition to support management of critical care. Also critical care involves high complexity decision making to assess, manipulate, and support vital system functions, treat a single or multiple vital organ system failure, and or prevent further life-threatening deterioration of the patient's condition. Some examples of vital organ system failure include central nervous system failure, circulatory failure, renal shock, hepatic, metabolic, respiratory failure. These are just some examples and even though critical care typically requires interpretation of multiple physiologic parameters or applications of advanced technology, critical care may be provided in life-threatening situations without these elements present. Critical care services can be provided on multiple days even if the patient's condition does not change or the treatment that you render does not change, but you must be able to validate that the condition does continue to require the level of attention that meets the definition of critical care. So if you're rounding and the patient's stable and there are no interventions and you don't do really anything except just look at the patient's chart, examine the patient, that's more than likely a subsequent hospital visit for that date of service if the patient is stable and doing well and that would be billed with 99231 to 99233. Providing medical care to a critically ill and injured or post-operative patient that must qualify for critical care if the illness and or injury and the treatment provided meets the definition the requirements of critical care. Now where can critical care services be performed? They can be performed in any setting. It could be on a unit in the critical care unit, the coronary care unit, the ICU, the neuroscience critical care unit, pediatric ICU, respiratory care unit, emergency department. It can be provided in any setting as long as it meets that definition of critical care and that means patients who are critically ill or unstable with a high probability of imminent life-threatening deterioration. Now for critical care services we have time elements which we'll discuss in just a second. So for critical care services 99291 and 99292, less than 30 minutes is not reported with critical care. It would either be reported with the initial hospital or observation care codes 99221 to 99223 or the subsequent hospital visit codes 99231 to 99233. From 30 to 74 minutes and that's per date of service so a calendar date. So if you see a patient for 45 minutes today you would bill 99291. 75 to 104 minutes you would bill 99291 and 99292. And then it goes on and on 105 to 134 minutes 99292 would be reported twice. For 135 to 164 minutes 99292 would be reported three times and for 165 to 194 minutes we report 99292 four times. Of course 99291 is always reported first because that's the initial critical care code for the first 30 to 74 minutes. Now this is CPT's definition. Now we've had some changes in 2023 for the definition for CMS for your Medicare Medicaid patients. Now as far as other payers we're not sure how they are going to determine this if they're going to follow CPT rules or CMS rules. Now let's look at what CMS definition of time elements for critical care has evolved to. In the Medicare Physician Fee Schedule Final Rule in 2022 which was last this year this current year in January they had intended to clarify that in order to bill critical care the time element would be different but it wasn't clear so they reclarified it in the 2023 Medicare Physician Fee Schedule Final Rule that in order to meet the criteria for CPT 99292 you had to exceed 104 minutes. So for CPT the first 30 to 74 minutes is 99291 and if you hit that 75 minute threshold you could bill 99292. For CMS you cannot you have to hit 104 minutes and go into minute 105 in order to bill for 99292 one time. So this is the time threshold 134 minutes for 99292 twice 164 minutes for 99292 three times and 194 minutes for 99292 four times and of course 99291 must always be reported as the initial critical care code per date of service per specialty per group if you're in the same specialty or some subspecialty working together in the same group. You can split share the visit with an APP so if you have split shared services we're going to talk about what that means a little bit later on but the split share time counts so all the time that everyone in your same group same specialty or subspecialty managing that patient that time is counted per day but again CMS has changed the threshold of time. Now do we know what other payers are going to do about this? We do not. Hopefully they will follow CPT's definitions and rules for critical care services but they may adopt CMS's time threshold. We do not know so we have to pay close attention to see what the payers will do in 2023. So when do you not use critical care codes? If patients are in the ICU and they don't meet the definition of critical care sometimes they're put in the ICU to monitor but they're not technically critical but there is a high probability that they could turn critical so they're being monitored so typically if they're not critical at the time you see them it's not critical care. It would be a subsequent hospital care visit. Typically it would be 99231 to 233. For patients during the post-op global period whose critical care is related to the surgery typically it's a condition that they are going to become critical or they are critical post-operatively and they're being managed by the surgeon. When critical care does not meet or exceed 30 minutes if it's under 30 minutes then you report the appropriate subsequent care hospital E&M service 99231 to 233. With rounding in the critical care unit for a patient not meeting the critical care requirements or definition it's a subsequent hospital care or if it's not related to an operative procedure that's non-global care and I'll just tell a quick story. I do a lot of audits. I audit a lot of critical care services as a consultant and I was reading a note where physician reported critical care time for a patient that was alert oriented sitting in a chair reading a newspaper. Now you would have a hard time justifying it to a payer to pay for that critical care services when technically it does not meet the definition and for patients receiving palliative care palliative care is not considered a critical care patient. So what's included in the time calculation of critical care? Providing service at the patient's bedside, discussing the patient's condition with other practitioners and members of the patient care team on the unit and immediately available to the patient. Reviewing data related to the patient when on the unit and immediately available to the patient. Procedures that are considered bundled into critical care which we'll talk about in a moment. Discussions with the family for family discussions the physician if they're not able to obtain a clinically relevant history then you can count that towards critical care. If you are giving them an update on the patient's condition that is not counted towards critical care. So documentation if you're doing family discussions you should document patient unable or incompetent to participate in giving history and or making treatment decisions. This necessitates to have the discussion. No other source was available to obtain the history because the patient was deteriorating rapidly. I needed to immediately discuss treatment options with the family or you could say medically necessary treatment decisions for which the discussion was needed and then summary in the medical record that supports the medical necessity of the discussion and any other discussions no matter how lengthy may not be counted and telephone calls to give patients an update may not be counted. But if you're calling a family member to make critical care decisions about that patient's care and you must obtain that information that does count towards critical care time and you need to just document it clearly and writing notes in the chart when on the unit in your EHR and immediately available to the patient is part of that critical care time so it should be counted. So let's talk about what services cannot be included in calculation of critical care. As I said before updating family members if you're just updating the family member teaching time with residents med students app's any teaching time is not included. Time spent off the unit now it's a little bit different with tele ICU when you're billing critical care and for telehealth you're not going to typically be in the unit but you are going to be available via audio visual synchronization so that's the key. Time spent caring for other patients time spent on telephone calls any activity that does not directly contribute to treatment of the patient performing procedures if you're billing a CPT code for a procedure that is not included in critical care time that time has to be excluded it has to be carved out of your total critical care time. Time spent in typical follow-up for all patients if you're doing rounding that would not be critical care time and for Medicare patients time treating complications that the patient does not have to go back to the OR. Now if it's not related to the surgery so if the patient let's say they had to have a craniotomy they had a car accident had injury they had a craniotomy and during the course of their critical care management the patient suffers an acute MI the MI is not expected it's not related to the actual craniotomy procedure it's not typical complications of the procedure then critical care can be reported that's just an example. We talked about services that were not in the critical care time calculation but these are the things that are included in critical care time calculation you cannot build them separately with a separate CPT code but you can count the time that you're performing these procedures they're what we call bundled into critical care interpretation of cardiac output measurements chest x-rays pulse oximetry blood gases interpretation of physiologic data gastric intubation a TTP that management is included in critical care time and peripheral vascular access procedures all these any service that is not listed here with their applicable CPT code can be billed separately and not included in critical care time but if you're performing if you're if you're actually doing a gastric intubation or taking blood pressures or collecting interpreting physiologic data that is included in critical care time and should be counted some common procedures performed in critical care that I see just examples this is not all inclusive any procedure that's not on the inclusion list for critical care which I showed you in the previous slide can be reported separately an endotracheal intubation is not included swan scan catheter CPR a non-tunneled central line a chest tube insertion a TTP these are not included it's this is not all inclusive on the list but here's the key the time devoted to these procedures must be deducted from your critical care time calculation so let's say it takes you five to ten minutes to insert a chest tube deduct those five to ten minutes from the critical care time calculation and document that now there's two ways to do it you can say I spent 45 minutes providing critical care services at the bedside to the patient I spent an additional five minutes inserting a chest tube or you can say I spent 40 50 minutes excluding five minutes inserting a chest tube for for the critically ill patient either way it has to be clear it's cleaner if you put total time critical care 45 minutes chest tube insertion five minutes it makes it clear you don't want to pay her to make their own interpretation CPR is not bundled into critical care that's CPT 92950 it can be billed separately again you must carve out that time it has to be excluded from the critical care time document the time you spent on the CPR and document the time you spent in critical care it's always good to document procedures separately including that time associated so if you're performing if you're managing a critically ill patient then you have to perform CPR document a separate CPR procedure note to make it clear that these are two separate services that should be billed separately critical care time should be the actual time spent evaluating and managing and providing care directly to the critically ill or injured patient the practitioner cannot provide services to any other patient during that time when they're providing critical care they must be immediately available to the patient at the immediate bedside or elsewhere on the unit or ward and again for critical telehealth you have to be available audio visual synchron audio visual which is a synchronous telehealth services time that can be counted for critical care include ordering reviewing lab tests results discussing critically ill patient with other practitioners or medical staff that includes a nursing staff even if it's not at the bedside you're still managing that patient as long as you're paying full attention to managing that critically ill patient again just as a reminder for medicare under the medicare physician fee schedule 2023 final rule they emphasize that 99291 is used for a minimum of 30 to 74 minutes only once per day per group per specialty so if you're in a multi-specialty group and your different specialties that's not the same once per day per group per same specialty if the time even if the time is not continuous so you see the patient in the morning you go back in the afternoon and you're managing the critical care you see them in the evening managing critical care that's non-continuous time on the same date service once you meet that 74 minute threshold typically for cpt we use 99292 but cms is saying when you have spent at least 104 minutes providing critical care you would report 99292 and that's different from cpt guidelines because if you have 75 minutes for cpt guidelines then you can report 99292 and this time does include split shared services and it can be aggregated by the same specialty group so you're the same specialty or subspecialty within the same group managing the patient together now let's look at a few examples of critical care services you're called emergently to the patient's bedside the patient is hypovolemic or hypoxic or another organ system is clearly at risk you mean your immediate intervention is required and you spend at least 30 minutes and documentation supports critical care you would build critical care services following a cardiac procedure 65 year old woman has a cardiac arrest associated with a pulmonary embolus physician spends one hour managing the critical portion if it's unrelated to the surgery and supported by documentation bill critical care if it's part of potentially the post-operative complication you would build subsequent hospital care or if it's post-operative and there's a global period of 90 days it would not be billable the patient is in the icu stable and moving towards discharge to next level of care no intervention or organ system issues remain you build subsequent hospital care but if you're the surgeon and it's during the post-operative period it would be included in the post-operative care and not billable let's talk about concurrent care so an advanced practice provider whether they're a pa or an mp or cns they will have their own taxonomy code however they are considered to be part of your group if it's the same specialty and subspecialty as a physician or group with whom he or she is working and again that's regardless of their taxonomy code they may provide concurrent follow-up care subsequent to another practitioner's critical care visit it might be continuous staff coverage or follow-up care provided on the same date and time can be aggregated to meet time requirements of 99291 which is the first 30 to 74 minutes also keep in mind if you as the physician and the app are seeing the patient together at the same time only the time for the primary provider can be reported so you can't report critical care twice for the two different providers who are seeing the patient together let's look at this example so let's say this is dr a who sees a critically ill medicare patient for 45 minutes and then later in the day the physician's pa manages the patient for 34 minutes with a total of 79 minutes for this date of service only cpt code 99291 would be reported 99292 is not reported unless an additional 30 minutes of critical care time is realized so you have to exceed 104 minutes for medicare for 99292 now if this is a non-medicare patient using the cpt guidelines and the payer uses cpt guidelines you must exceed the 74 minute threshold to report 99292 so let's say you have a different specialty managing critical care so you have two practitioners managed managing different portions of critical care services or different organ system compromise the service has to meet the definition of critical care they may require the care of more than one physician of a medical specialty it must be medically necessary and it cannot be duplicative so the cardiologist managing the patient who had an acute mi patient who also has a pulmonary embolus the pulmonologist is managing the embolus the cardiologist is managing acute acute mi so in this example we have the cardiologist the acute mi 66 minutes they would bill 99291 for their 66 minutes pulmonologist spends 45 minutes managing the pulmonary embolism and that would be 99291 for the pulmonologist so each would report that and their diagnoses would reflect their first listed or principal diagnosis would reflect that they're managing a different part of the critical care service even on the patients in the critical care unit or maybe a critical patient it's not always critical care unless interventions are being provided rounding on a critical but stable patient with no interventions is most likely a subsequent hospital care visit 99231 to 99233 so if you have a patient that you provided an enm service let's say an initial inpatient or observation care code 99221 to 233 let's say you reported a 99222 they're coming in for chest pain they're being admitted interqual allows admission based on the diagnosis and the problem the patient is experiencing and they're not critical they do not require critical care but now they're critical care they've suffered an acute mi and now they're critical so if the enm service was provided by the same practitioner or same practitioner in the same group and that includes the advanced practice provider working in your group same specialty you can build that enm service later if they become critical then they meet the definition of critical care and you're providing critical care services you can build 99291 and 99292 based on time and append modifier 25 to the critical care service to say that it's significantly separately identifiable your diagnosis codes will be different and that's the key to support medical necessity for the critical care so you have a patient admitted as an inpatient severe chest pain shortness of breath cardiologist sees the patient admits the patient bills 992323 for the initial inpatient or observation care stay later in the day cardiologist summoned to the patient's bedside patient had an acute mi your transfer to critical care unit physician spends 45 minutes stabilizing the patient physician would bill 99223 for the first initial hospital care code also 99291 modifier 25 for the first 30 to 74 minutes of critical care and again modifier 25 is important because it identifies it's significantly separate from the initial visit that that cardiologist spent earlier that day and your diagnosis codes will drive medical necessity the cpt code and principles require that any time you have a service performed prior to midnight and it continues past midnight so it's performed continuously and there's no disconnection in service the time is accrued and reported as occurring on the pre-midnight date so for example on 12-1 you see a patient they're admitted from the ed with hypotension hypoxia they require respiratory and circulatory support you manage that patient beginning at 11 30 pm on 12-1 and on 12-2 you complete managing that critical care patient at 12-20 so you're going to use the date of 12-1 as your date of service and continue the time from 11 30 pm on 12-1 through 12 20 am on 12-2 so it's going to be continuous but billed as the pre-midnight date let's look at this example we have a 45 year old non-medicare patient admitted to the neuro ICU had a motor vehicle accident close head injury 11 15 pm november 15th that's when critical care began critical care physician provided care continuously from 11 15 to 12 45 am on november 16th so in this situation we would bill 9 9 2 9 1 for the first 30 to 74 minutes of continuous care and 9 9 2 9 2 for the additional 30 minutes or a total of 90 minutes since this is a non-medicare patient and hopefully the commercial payer or whoever the payer is follows the cpt guidelines instead of medicare guidelines but let's say this is a 65 year old patient on medicare if this was a medicare patient we could only report 9 9 2 9 1 with the date of service november 15th which was the origination date because medicare will not allow payment for 9 9 2 9 2 until the 104 minute threshold has been reached so now let's expand this example a bit with our 45 year old neuro ICU patient following the motor vehicle accident close head injury 11 15 pm on november 15th they're being managed up to 12 45 am on november 16th so that's the november 15 2022 we're going to bill 9 9 2 9 1 and 9 9 2 9 2 for a total of 90 minutes again they're not a medicare patient cpt guidelines are being followed later in the morning the patient's condition deteriorates same physician is summoned to manage the patient it could be a different physician within your group and your same specialty you're still one in the same so later in the morning the patient's condition deteriorates and the same physician is summoned to manage the patient. The critical care physician spends 45 minutes on November 16th from 9 to 9.45. That's 45 minutes stabilizing the patient. So now on November 15th we're reporting 9.9291 and 9.9292 for 90 minutes. On November 16th we're now reporting 9.9291 for the 45 minutes of non-continuous critical care time. I actually get this question a lot. Can you build critical care after the patient is deceased? So you've been providing critical care and now you're providing comfort care and you meet with the family and discuss end-of-life organ donations. This is not critical care. On the date of discharge, Medicare and other commercial payers allow the physicians to build discharge code 99238 or 99239. Again these are time-based codes. 30 minutes less or equal to 30 minutes is 99238 and if it takes longer 99239. What's included in the discharge is examining the patient, pronouncing them deceased, documenting in the electronic health record, documenting a summary. All of that time is inclusive and closing out the patient record. If it takes longer than 30 minutes it's 99239. You need to document total time spent. If the patient has already died and you show up to evaluate the patient, you cannot build critical care. You build a discharge. If you declare the patient dead and or manage organ donation, even if the patient died before you were able to see him or her alive. Once the patient is in donation status or pre-donation preparation, it's considered the organ transplantation billing. So you are no longer involved. The organ procurement team will do the billing. Now we will talk about split shared visits. Medicare defines advanced practice providers or APPs or what CPT calls other qualified health professionals as in the critical care realm. Physician assistants, PAs, nurse practitioners, MPs and clinical nurse specialists, CNSs. So what is a split shared service? It's a service performed in part by both a physician and advanced practice provider who are in the same group, same specialty or subspecialty, regardless of same or different taxonomy codes. Performed in a facility which is an institution setting in which payment for services and supplies furnished incident to or practitioner professional services is prohibited. So incident to services are prohibited in the hospital setting and they're allowed only in the office setting. So a split shared visit is allowed for both new and established patients, hospital E&M services and that includes your initial inpatient or observation services, your subsequent hospital visits, critical care and skilled nursing facilities. In order to qualify, the physician and APP must be in the same group with the expectation they're working together to furnish all the work related to the patient encounter. They must see the patient at different times in order to bill split shared, not together. If they see the patient together and only count, one practitioner can count. If they're in different groups, different specialties, each bills for his or her own service. So let's say you've got a pulmonologist managing the pulmonary embolus, the cardiologist managing the acute MI, the advanced practice provider for the cardiologist sees the patient, they're different than the pulmonologist. So they're a separate group, separate specialty. Even if they're in the same multi-specialty group, it's the actual specialty that will define it. Time spent by two practitioners in the same specialty who spend time jointly examining the patient, discussing the patient can count time only once when reporting split shared. And the practitioner with the substantive portion bills the critical care. So for Medicare, they allow 100% of the allowable for the physician. For the advanced practitioner, APP, it's 85% of the allowed amount. So as I just said, the visit must be billed by the practitioner who spends the substantive portion of the visit and it must meet the definition of split shared. So only one practitioner can bill the ANIM service when you're split sharing. And since critical care is time-based, time is the only consideration for substantive portion. So the person who spends 50% or more of the time managing the patient care, and that includes face-to-face time, talking with other practitioners about the patient's care, documenting in the EHR, documenting in the medical record, all of that counts towards the critical care time. And documentation must identify who performed the visit. So do you need to just use one note if you're split sharing? No. You can each create your own note, but the total time is going to define who it's billed under for the substantive portion of the visit. The practitioner who provides a substantive portion of the visit will sign and date the medical record, so they will be the one responsible for the medical record for that date of service. It must include time even if the practitioner who bills signs a note. You have to use modifier FS for split shared E&M service and that would be critical care or an E&M hospital 99221 to 99233 visit. You're either initial or hospital observation hospital inpatient or your subsequent hospital or observation care visit. It must have the FS modifier if you're split sharing. So this is a definition of modifier FS, split or shared E&M service. Each time a hospital E&M service is performed split share, the modifier must be appended. So this is what's going on with split share. So in 2023, they delay based on policymaking in the Medicare physician fee schedule in 2022 to determine which professionals should bill for a split shared visit and they just defined it as substantive portion. They did define it for critical care as being who has the most time, 50% or more of the time, total duration of time, more than half of the total time. In 2023, they have planned to change the inpatient hospital or subsequent initial inpatient or observation and subsequent hospital care codes to include time but they decided not to do that. So in 2023, they decided to delay that and the substantive portion comprises of the history, performing the exam, medical decision-making, and or spending half the total time by the practitioner. Now this is only for your inpatient hospital and observation or subsequent hospital and observation care codes 99221 to 99223. If you're billing an ED visit, let's say you see the patient in the ED and they're not critical and you're billing an ED visit 99281 to 99285, it's based on medical decision-making. Time is not a factor so it would be history exam or medical decision-making. So to finalize that, clinicians who furnish a split shared visit will continue to have the choice of history, exam, medical decision-making, or more than half the total time with the exception of the emergency department visit codes to determine the level of service for split shared until 2024 when they publish the proposed and the final rules for 2024 in the Medicare Physician Fee Schedule. The exception is critical care because critical care is a time-based service. So again, this slide just shows you in a nutshell the definition of substantive portion. Again, it's critical care is more than half the total time, just keep that in mind. Okay, let's look at this example of split share. Cardiologist managing a patient for an MI. Patient worsens. They spend 45 minutes managing the patient, the physician does. Later in the day, the cardiology APP is providing critical care to the same patient 30 minutes. That's 75 minutes total. The physician will bill 99291 because they spent the most time and the APP does not bill, but they bill a total of 75 minutes and they would bill under the physician's NPI number. Now let's look at the global period of the surgical procedure and critical care. So when is it appropriate to bill critical care outside of the global period of a surgical procedure? It has to be unrelated to the actual surgical procedure performed. The physician or their partner of the same specialty repairs a lacerated liver after trauma. Let's say you're managing the patient's other injuries and you're a different specialty. In the ICU and you manage the critical care, they have a hemothorax 40 minutes. You are billing that E&M service, that critical care service, because it represents an unrelated problem. They had a liver repair after trauma. You're managing other injuries that the patient has. It's unrelated to the reason or the surgical procedure itself. You have to report 99291 with modifier FT. What is modifier FT? It's an unrelated evaluation and management service visit during a post-operative period or on the same day as a procedure or another E&M visit. So if you have an E&M visit furnished within the global period, but it's unrelated to the reason for the surgery, it's outside of the global, it's unrelated, you use modifier FT. A critical care visit may be separately paid in addition to the procedure with a global period, as long as the critical care is unrelated to the procedure and the patient meets a different definition of critical care. It must be unrelated to the specific anatomic injury or surgical procedure that the surgeon performed. One of the things to keep in mind is sometimes the patient is critical by virtue of the nature of the procedure and critical care would not be reported. It's not appropriate for an E&M service or critical care service to be performed when the E&M service is directly related to the surgery. So let's look at three examples. Patient comes in hypotensive after abdominal surgery due to hemorrhage at the surgical site. It's related. Physician manages the patient during the post-operative period following a whipple for blunt abdominal trauma. You manage fluids and nutritional needs and monitor for complications included in the post-operative care. Physician manages the patient post-operatively in the surgical ICU, monitoring vital signs, metabolic status, very closely because the patient has comorbidities increasing the likelihood of complication. These are included in the procedure itself, not built separately with critical care. This is where it gets tough. What about a trauma surgical specialist, intensivist, or hospitalist? Is the encounter unrelated to the post-operative global service? If it is, you can report critical care. Are both physicians reporting critical care for the same clinical problem? That could be a problem in itself. Payers may expect different diagnoses for each if both are reporting critical care. It has to be unrelated. Payers may request documentation to support medical necessity and non-duplicative services. And trust me, they will ask for documentation in that instance. So be very cautious. Document, I's dotted, T's crossed. Documentation is in the details. So what should be documented? We need a detailed chief complaint. Why is the patient critical? Tell us why, what the condition is. Even if they're stable, we need to have that information to support medical necessity initially for critical care. We need for the actual initial encounter a complete history including past medical, family history, social history, medications, laboratory findings, vital signs, a well-documented exam, diagnostic tests that you've ordered, reviewed, or analyzed, any interventions that make this a critical care encounter, a detailed assessment, and then the diagnoses, the conditions you're managing. Give us the status of that condition. Is it stable, well controlled, inadequately controlled, exacerbating, failing to change, worsening, etc. Whatever your terminology is, tell us the status, the acuity of the problem. And your plan of care, make sure it is detailed. And do not document a range of time. Spend 30 to 74 minutes managing the critical care patient. No, no, no. You need to document the total time spent. A payer will not accept a blanket statement. Also, we need a description of all of the physician's interval assessments of the patient's condition, any impairment of organ system based on all relevant data available to the physician or the practitioner, signs, symptoms, diagnostic data, and your rationale and timing of interventions, and the patient's response to treatment. That's critically important. So let's look at some actual examples I've pulled from notes that I've reviewed over the years. We have a 75-year-old woman with type 2 diabetes on metformin and presents with cholecystitis, increased bilirubin, liver function tests, subsequently improved with antibiotics. She's had an episode of abdominal pain subsequently found to have ST changes. That's the rationale for critical care. What findings support critical care? There aren't any. We need more detail. This is another one. She's awake and alert, no oxygen. Chest is clear, no murmur, abdomen is soft. Extremities are not edematous. Cholecystitis, waiting for less inflammation, will probably have a percutaneous tube placed. Multiple medical problems will follow glucose. The assessment and plan does not support critical care. What are the multiple medical problems that make this patient critical? And this was an actual note where they billed 37 minutes of critical care time, including discussions with APP and patient, chart review and physical exam billed as 99291. This would not support critical care. Documentation needs to be improved. Let's look at this note. Patient remains critically ill due to need for ongoing intensive neuromonitoring, cardiopulmonary monitoring, respiratory monitoring, and support. Not enough detail. I spent 102 minutes providing critical care. Doing what? Where's the detail? Patient's plan was discussed in detail with a multidisciplinary team on grounds, including the bedside nurse. Primary team was made aware of the plan. What is the plan? Plan should be documented. So we have an unknown chief complaint, no assessment and plan, no documentation of the interventions, and they billed 99291 and 99292. Not good documentation. Now look at this note. We have a patient admitted to the ICU septic shock. Initial treatment involves intubation, placing a central line arterial line, ventilation, volume resuscitation, antibiotics, a non-epinephrine infusion initiated, titrated for mean arterial pressure management, ventilation or ventilator titration performed, an ECG arterial blood gas measurement, central venous oxygen, saturation determination, chest radiography interpretation. Of course, all of those, all of that data should be documented. And then time spent in critical care management as well as ICU admission is 119 minutes with 45 minutes devoted to procedures. Now we have a patient with acute respiratory distress syndrome, ECMO, blood loss, sepsis, immediate threat of organ system failure, 63 minutes spent evaluating ECMO respiratory status, multiple data sources, adjusting the clinical plan and conferring with consultants. Critical care time, 31 minutes, no detail. This is it. This is unclear documentation, no specific details to support the critical care. What are the multiple data sources? Document the respiratory status. What's the clinical plan? Who did you confer with? That's all important data that needs to be documented. Here is a man brought to the emergency department after developing severe shortness of breath, admitted to critical care with severe respiratory distress, acidosis. Critical care physician inserts arterial and central lines, intubates, and begins ventilator management. Patient also has primary colon cancer of the descending colon, managed by gastroenterology. Critical care physician spends 35 minutes managing the patient. So in this scenario, our critical care time is 74 minutes, 99291, modifier 25, because we're also going to bill for the arterial line not included in critical care, 36620. We're also going to bill for the central line, 36556, and for the intubation, 31500. Now these are not inclusive of critical care time, can be billed separately, but we always want to put the modifier 25 on the E&M service to say that it is significantly separately identifiable E&M service on the same day as a procedure or other service. And this allows it to bypass the edit of being bundled into the procedure. Now let's look at this scenario. We have an 80-year-old woman. She underwent a laparotomy for a perforated colon. She has cirrhosis, congestive heart failure, renal failure. She's requiring hemodialysis. She's in the ICU. She's intubated. She's unstable. We've got her central venous pressure, systolic blood pressure, heart rate documented. The resuscitation, crystalloid resuscitation continued. She responds to the resuscitation. The family is met with, discuss the care plan and the goals of treatment. Because of her state medical comorbidities, the family is told she's critically ill, prognosis grave. Family refuses to sign a DNR. Patient wishes are for aggressive measures to be taken according to the family. Physician spends 30 minutes. That supports critical care, 99291. In the early evening, you're called urgently to the bedside. Find the patient bradycardic. She loses pulses. Team begins CPR. Advanced cardiac life support protocol is followed. 20 minutes, no return to spontaneous circulation. Time spent 25 minutes. Family gathered in the waiting room. You tell them what happened. Answer questions and spend 20 minutes providing support. Okay, 99291 is going to be for the 30 minutes for the initial admission to the ICU, plus 25 minutes spent evaluating the patient before you call in the CPR team. That's 55 minutes, and then the time spent with the family is not inclusive and not separately reported. Now, keep in mind that the time spent performing CPR is not included in the time spent performing CPR is excluded from the critical care time, the 92950, so you have to carve out that time. How much time of that 25 minutes is spent on CPR? It looks like 20 minutes, so you would have 30 minutes plus five minutes of managing critical care, so that would be 35 minutes, and that still would be 99291, but you're going to bill 99291 with the modifier 25, the 92950 for CPR that is separately identifiable, and then the time spent with the family is not doable. We have a 68-year-old man, six days post-op after a whipple, acute onset shortness of breath. You evaluate him in his room on the medical surgical ward. He appears in distress. He's tachycardic. He's hypoxic. He feels as if he cannot breathe. He's using his accessory muscles to breathe. The anesthesia team intubates. We spend 25 minutes. He's transferred to the ICU. Further workup reveals saddle pulmonary embolism. Radiology and lab findings are reviewed, adjusting ventilator to optimize oxygenation, and then anticoagulation is started. Time spent, 20 minutes, so we would bill 99291 because, remember, we can bill critical care in any place of service, so 99291 would be reported for this encounter. So, in summary, documentation should paint a picture of the patient's condition. Keep in mind that medical necessity drives every patient encounter. We need to document always the organ system at risk. Why are they critical? What's the organ system at risk? Which diagnostic or therapeutic interventions were performed, including the rationale behind it, critical findings of lab tests, imaging, ECGs, etc., and their significance, course of treatment, the plan of care, the assessment of that patient, and the acuity of the conditions, the likelihood of life-threatening deterioration without intervention, and time spent, total time spent on adult critical care minus procedures that can be billed separately. Keep in mind also that your diagnosis coding is very important for any specialty but critically important when managing a critical care patient. Your coding and documentation should always tell the payer why and what services are performed and the reason for providing the critical care service. So, how to improve your documentation? Provide specific examples of potential or actual organ system failure, hypodynamic instability, mental status, any alterations. Document multiple data review, intensive monitoring, complex decision-making. So, here's an example. Patient with head injury and loss of consciousness requiring frequent neurologic monitoring and data review. Patient with acute stroke and hemiplegia requiring frequent neurologic monitoring, imaging, and data review, as well as urgent coordination with multiple specialties. You can add that as a summary to your note. Also, document and code all diagnosis and comorbidities that affect patient care, and keep in mind your first listed diagnosis should be what you're managing, the condition or conditions you're managing, and then the comorbidities follow. Document the acuity severity of all your diagnoses, whether it's acute, chronic, acute-on- chronic, exacerbation, and adequately controlled worsening. List all conditions related to the underlying cause if you know it, sepsis due to pneumonia. Clarifying the documentation, any conditions that are present on admission, that's important, and document any suspected or rule-out conditions, but also document the signs and symptoms so they can be coded. Confirm any uncertain diagnoses or suspected diagnoses. Confirm uncertain diagnoses at time of discharge. And total time must be documented, not a statement saying a range of time, but total time documented, and then carve out exclude your procedures. And medical necessity must be evident that the patient is critical, and in the case of a post-surgery patient, critical care is unrelated to the injury or procedure. So now let's look at some key changes at the hospital non-critical care codes. So some of the key changes for 2023. Inpatient and observation categories are combined now. The 99221 to 2233, and we'll talk about those. Observation inpatient admit and discharge same day are still retained, 99234 to 236. So if the patient is admitted as an inpatient and they're sent home that same day, we would code this category. Level one consultations for inpatients have been deleted, 99251, because all the categories converted from history, exam, medical decision-making method to medical decision-making or time methodology. And the exception is the emergency department, which is based on medical decision-making only. And we call that MDM. Some of the categories apply both to new and established patients. Hospital inpatient or observation, that's a new terminology. And they differentiate whether the service is initial or subsequent. If you want to distinguish between the initial and subsequent visits for professional services, and that's for the physician and APP services, they are face-to-face rendered by a physician or other qualified healthcare professional, QHP, which are your APPs who can report E&M services. The initial service is when a patient has not received any professional services from the physician or QHP in the same group, same specialty or subspecialty during the inpatient observation or a nursing facility admission or stay. This is new terminology. And the subsequent service is when the patient has received professional services from the physician or QHP or another physician or QHP in the exact same specialty or subspecialty in the same group during the admission and stay. So, the other rule is if the physician or other QHP is on call or covering for another physician or QHP, the patient encounter will be classified as if it would have been by the physician or QHP who is not available. And when an APP and physician assistants are working with physicians, they are considered as working in the same exact specialty and subspecialty as a physician, even though they have a different taxonomy code now. And a hospital inpatient or observation care service includes a transition from observation to inpatient in a single day. So, if the patient's observation status are being admitted on the same day, that's considered, the transition is considered reporting inpatient or hospital observation care services and combining those. So, there's no distinction between new and established patients in the ED because there's no distinct distinction between new or established or initial or subsequent. Total time on the date of the encounter is by calendar date. And when you're using medical decision-making, MDM or time for the code selection, and a continuous service that expands the transition of two calendar dates in a single service is reported on one calendar date. And we did cover that initially with Greg's example. So, if you're using MDM or time for critical care, if it starts on one calendar date and is continuous through the next calendar date, if you're using time or medical decision-making, that total encounter is considered build on the date of service where the encounter began. And if it's continuous before and through midnight, it's the date of service where the an initial service may be reported when the patient has not received any professional services from the same specialty by the physician of the same specialty in the group or other QHP within the group, the advanced practice providers during that admission. And the guidelines also expand that when an APPs are working with physicians and they are considered as working in the exact same specialty and subspecialty as the physician. This is a new guideline that's different from previous years. In past years, if you admitted a patient from the ED or the office, you only report the initial hospital care code. You would not report the office visit code or the ED visit code or nursing facility code if you are the physician admitting the patient. But now, if you initiate the encounter at a different site of service, whether it be ED, office, nursing facility, you can report that code. And also you can report the hospital care code with modifier 25. However, you cannot report an inpatient consult or you cannot report the initial hospital or observation care. You have to report subsequent care codes 99231 to 233 for the second service on the same day. So you're going to bill an ED visit, you're going to bill a subsequent hospital care code. If they're in the ED, you see them in the ED, you decide to admit them on the same date, you're going to bill both codes. If you perform a consult that's related to or anticipation of the admission, and then you perform an encounter once they're admitted, the same rule applies. You would report the subsequent care code as your second code. You may be providing inpatient consultations at a request from another physician or qualified healthcare professional. And when the patient has not received any face-to-face professional services from anyone in your group, whether it be an APP or a physician in your same specialty and subspecialty, you can report 99252 to 99255 if you're being asked to provide a consultation and recommendations for care. And then again, when advanced practice providers, APPs are working with physicians, they're considered as working in the exact same specialty and subspecialty. Only one consultation may be reported by a consultant per admission. And subsequent consultation services during the admission are reported with 99231 to 99233, which is your subsequent inpatient or observation hospital care codes. For 2023, let's look at medical decision-making or time to select your hospital level of service. CPD codes 99221 to 223 for inpatient or hospital observation, the initial care, or subsequent hospital or observation care by either medical decision making or time. First of all, let's start with medical decision making. There are three elements to medical decision making. There's the complexity of the problems addressed, the amount and or complexity of data to be reviewed or analyzed, or risk of mortality and morbidity in patient management. Two of three of those elements have to be met in order to select the level of service. So we'll start with the three elements and then put it all together to show you how that evolves. First, the definition of a problem addressed. That's part of the complexity of problems addressed. It's a problem that's managed, evaluated, or treated at the encounter by the physician or other qualified healthcare professional reporting the service. It includes consideration of testing, treatment that may be elected, risk and benefit analysis of the patient. Now if you are noting in the patient's record that another practitioner is managing the patient without additional assessment or care coordination, that does not count as the problem addressed. A referral without evaluation by history exam or diagnostic study does not qualify. And for inpatient and observation care services, the problem addressed is the problem status on the date of the encounter, which is different from that of the date of admission. If it's not being managed by you, if it's a comorbidity that affects management of care, of course you're going to document it, but it does not count in the complexity of problems addressed. Let's look at what these problems mean. We have straightforward low, moderate, and high for medical decision making. A minimal problem is a problem that does not require the presence of a physician or QHP under the physician or other qualified healthcare professional supervision. Now you wouldn't build that in the inpatient setting for 99221 to 99233. Most of the time you wouldn't have a minimal problem if they're in the hospital. Straightforward is a self-limited or minor problem that runs a definite and prescribed course of treatment, is transient in nature, and does not affect permanently the health status of the patient. Or you could have low complexity, and that's straightforward, one self-limiting or minor problem. If you have two or more self-limiting problems, that's low complexity. So that's two problems that are transient in nature and not expected to permanently alter health status. Chronic illnesses. A stable chronic illness is one that is stable at treatment goal. It's a problem that's expected to last at least a year or until the patient dies. It needs to be documented as chronic. Even though it's a chronic condition, it's always best to err on the side of safety and document that it is a chronic condition in case a payer is looking at your records and maybe someone that doesn't work in your specialty and doesn't know if it is chronic or not. So if it's chronic, document chronic. If it's that treatment goal that's stable, then it is a low complex problem. One stable chronic illness. If you have an acute uncomplicated illness, it's a short-term problem, low risk of morbidity, normally self-limiting or minor, not resolving, consistent with the defined and prescribed course of an acute uncomplicated illness. And they give you examples of cystitis, allergic rhinitis, or a simple strain. That's an acute uncomplicated illness. That's low complexity and the problem is addressed. Now moderate and high is typically where your hospital patients are going to land in most cases for the types of patients you treat. So now we have moderate complexity. One or more chronic illness with exacerbation, progression, or side effects of treatment. They're not a treatment goal. It's worsening, inadequately controlled, failing to change. So you have to document that it's chronic. You also have to document that it's exacerbating or failing to change or inadequately controlled. Tell us it's not a treatment goal. So it's again a chronic illness. It's expected to last for at least a year or until the patient's death. And the intent that it's poorly controlled or progressing and your goal is to control that progression and it requires additional supportive care by a practitioner. A stable chronic illness, if you have two or more stable chronic illnesses that you're managing, again it has to be something that you're managing or treating. It's moderate. An undiagnosed new problem with uncertain prognosis. So you may have a patient who has a mass and you are going to do a biopsy to determine or a procedure to determine if they have a mass, if that mass is cancerous. Then that would be a new problem with uncertain prognosis. CPT gives the example of a lump in the breast. An acute illness with systemic symptoms, fever, body aches, fatigue, an illness that may be treated to alleviate symptoms. They're generally systemic symptoms. It might involve more than a single system, but it may just be a single system. So an acute illness with systemic symptoms or an acute complicated injury is considered moderate in complexity. So you have an injury that requires treatment involving the body system and other body systems that are part of the injured organ that is extensive for which treatment options are multiple or associated with morbidity risk. A head injury with brief loss of consciousness is a great example of that. High complexity is one or more chronic illness with severe exacerbation progression or side effects. It's a chronic illness that's severely exacerbating and you have to document the severity. Side effect of treatment, significant risk of morbidity. It does require, in most cases, a hospital level of care. So a lot of your patients, the complexity of the problems addressed are going to be high. An acute or chronic illness that poses a threat to life or bodily function, that would be high complexity. In this case, an acute MI or pulmonary embolus would require critical care services in most cases. Severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness, potential threat to others, and a brief change in neurologic status would be examples, good examples of high complexity. So it is you as a provider, it's your responsibility to document each problem address that you're addressing and managing. Document the acuity of the problem, stable, chronic, acute, exacerbating. Is it chronic severe? Is it chronic moderate? Tell us what level it is for the acuity so we know what level the problem addressed is for the complexity of the problem. Turn to element two, amount and or complexity of data reviewed and analyzed. So we have straightforward, low, moderate, and high. So this is the data, reviewing external notes and a unique source is someone other than someone in your practice. So it could be coming from family practice, or if you're pulmonary, it's coming from cardiology. It could be a review of notes that are in the medical record from another source, a unique source, a review of the results of each unique test. So if you're not billing for the test and you're reviewing the test, you can count this in this element. If you're ordering the test, but not billing for the test, you can count this, but if you're ordering the test and billing the test, it's inclusive in the order. So you only get one point for credit for ordering the test. If you're billing for it, you don't get credit because you're getting paid extra for that test. But in a hospital setting, you're going to be ordering these tests, but you're not going to be billing for the tests. You're going to be ordering them. You're going to be reviewing the test results. And that counts towards the element, amount, or complexity of data to be reviewed and analyzed. So in category one for low complexity, any combination of two. So if you review external notes and you're reviewing test results for each test that you review, it counts as a point. You get two points, it's low complexity. Or let's say you need an independent historian. The patient cannot respond, they cannot give or provide the history to you, that information that you need to manage the patient. That is an independent historian. An independent historian is not an interpreter. They're just actually conveying what the patient is saying in their own language or their own words where you cannot communicate with them directly. Moderate in this category, any combination of three is moderate for category one. So reviewing prior external notes from each unique source, reviewing results of each unique test, ordering each unique test, assessment requiring an independent historian. That was category two in low complexity. It has moved up to moderate in category one. Category two, independent interpretation of tests, and that's an independent interpretation of a test performed by another physician, not separately reported. You can't bill for that x-ray, you can't bill for that test, but you're doing an independent interpretation and documenting that independent interpretation. Not that you reviewed the results and made your decision and plan of care on those results, but that you're actually interpreting it. That counts as moderate. Or discussion of management or test interpretation. If you're discussing the test interpretation with the provider who performed and analyzed the test, provided a written report, you discuss that with them, you get credit in category three. If you're discussing management of a patient with another practitioner, an external physician, not somebody in your group, somebody outside of your group that you're conferring with and managing the patient, that counts as category three. In category one, you need a combination of any of these three, reviewing the notes, reviewing the test results, ordering each unique test, and that's for each unique test. If you're ordering and reviewing, that counts as one, ordering and includes the review. If somebody else orders the test and you're reviewing the results, you get credit for the review. And I'll say that again, if you're ordering a test, the review of that test is included in that order. So you don't get credit twice, only once. But if you do not order the test and you're reviewing the test, you do get credit for that category one for reviewing those test results. So three out of the combination for category one, or category two, the interpretation, the independent interpretation, or category three, discussion of management of test interpretation or test interpretation. So either discussing management of the patient or discussion with someone about the test interpretation who performed the test is considered category three. That's moderate complexity. Now if you meet high complexity, you have to have two out of these three categories. So either combination of three from category one and a category two, a category two and a category three, a category one and three. So you have to have two out of those three. Now let's move to the third element, which is risk. So this is risk of complication and or morbidity or mortality of patient management. So this in your plan of care, what are you doing overall? How are you going to manage the patient? Straightforward is minimal from additional diagnostic testing or treatment. Low risk is low if you're giving them over-the-counter meds or an aspirin, that could be low risk. But if you're writing a prescription, if you're actually giving them a prescription drug, that would be moderate risk. Minor surgery with identified patient or procedure risk factors. Risk and benefits discussed with patient is not sufficient. You have to document the specific risks of the procedure, like bleeding, possible death, whatever those risks are for that particular procedure. A discussion regarding elective major surgery without identified risk factors. That's where you're discussing a major surgery, but you just say risk and benefits were discussed. That's without identified risk factors. And diagnosis or treatment significantly limited by social determinants of health. And that would be the patients in the hospital. Maybe you're talking to them about medications, they can't afford those medications. That could be a treatment that's impacted by the fact that they cannot afford those drugs. That would be an example, or maybe they have limited housing or fuel for their furnaces or shortage of clothing or whatever the case might be. The social determinants of health has become a big factor recently in the past few years. And then high complexity for risk regarding elective major surgery with identified patient and procedure risk factors. So surgeons, when you are determining a major procedure with a patient or the family, if the patient's unable to give their consent, you have to identify specifically in the documentation what those risk factors are. You can't just say procedures and risks discussed with patient and or family. Discussion regarding, decision regarding major surgery, decision regarding hospitalization while they're already in the hospital. So if you're making the decision to admit them, that's where it comes into play. Decision not to resuscitate or to deescalate care because of poor prognosis. Drug therapy requiring intensive monitoring for toxicity, not efficacy, but for toxicity and parental controlled substances. That would be considered high for risk. It's a tough part, putting it all together. So first of all, you have to select a level based on the number of complexity of problems addressed. You have to look at the amount and or complexity of data to be reviewed and analyzed, and then the risk of complication and or morbidity or mortality of patient management. Two of three elements on the table indicate the level of service. So we have a patient who has a chronic illness with exacerbation. They're having severe shortness of breath, it's exacerbating. So that's one or more chronic illness with exacerbation. Now you said severe exacerbation. That would fall into high complexity. It's a terminology that you use. So you have an undiagnosed new problem, you have a mass, you're recommending a biopsy. That would be undiagnosed new problem, that would be moderate for complexity. So now the amount of complexity or data to be reviewed. Let's say you order some labs. So you order one lab test. Now keep in mind one lab test is the CPT code. It can be a combination of several tests within one CPT code, but that's considered one lab. Let's say you order a CBC and a TSH. So those are two separate labs. That would be two points for the review of, for the ordering of each test. And let's say that this is a patient who we need an independent historian because they are unable to communicate. They can't give you the information, maybe they have dementia. So you have to get the information from a family member. So that would be category two, assessment requiring an independent historian. Well if you look at moderate for the amount of complexity of data, you can see that ordering each unique test, which we ordered two, and the assessment requiring the independent historian comes out to three, we have met moderate complexity for category one. So we would have moderate for the amount of complexity. And let's say that you are, this is a patient who's diabetic, maybe they have dementia, they have COPD, and they have other comorbidities that the patient's family, even the caregiver, the person who actually has the power of attorney to make the decisions, decides not to resuscitate the patient or to deescalate care if necessary. That would be high for risk. So we have one or more chronic illness with severe exacerbation, we said severe. Now we have moderate for category one, we ordered two tests, and we have an independent historian. And now we have a decision not to resuscitate or to deescalate care because of poor prognosis, that would be high. Two elements on this table is high for complexity of problem, and risk would be high complexity. And let's say this is the initial hospital care, 99221 to 99223, this is the first time you've seen them during this admission, and that would be a 99223 because we're basing it on medical decision making. Another scenario, we have a patient that's having shortness of breath, it's chronic, they have COPD, it's exacerbating, that would be moderate. One or more chronic illness with exacerbation, it's inadequately controlled. We've ordered two tests, so we've ordered some labs, so that would be low for the amount of complexity of data to be reviewed. And let's say we ordered two tests and then we decide to go ahead and order, let's say a CT of the chest. So that would be another test. So that would be three. So now we move to moderate for our amount and or complexity of data to be reviewed and analyzed. And then for risk, let's say we are managing the patient with medications, prescription medications in the hospital, and that would be moderate for risk. So we've got moderate for the complexity of problems addressed, we've got moderate for the amount of data or complexity of data to be reviewed and analyzed, and we have risk that falls into moderate. All three are met, two of three have to be met, it's moderate complexity, it would be a 99222. To recap, with medical decision-making, it's the amount of complexity of data to be reviewed or analyzed, it's the complexity of the problem addressed, and it's risk. And that risk table that was on the previous slide is your guide as to what level you should select, a level one, a level two, a level three. So let's look at time. You can use time as the alternative. You don't have to use medical decision-making for your hospital visits, your initial hospital care or observation care, or subsequent hospital care or observation care codes. With the medical decision-making, two elements on that medical decision-making table have to be met based on problems addressed, data, and risk. But time is the total time on the day that you perform the service, that includes face-to-face time and non-face-to-face time. Okay, so what are the time qualifiers? Any time performing a procedure is not counted, for it's the E&M time. Time spent by auxiliary personnel, the nursing staff, is not included. It's the time that you as a practitioner perform. Time and activities performed by physicians or QHPs that are normally performed by auxiliary personnel do not count. And time required for a translator or interpreter on the same day does not count. And time is excluded if you're in the ED seeing the patient. It's not applicable to emergency department 99281 to 285. The history examination should be medically appropriate, and the provider determines this. So it's you as a provider's decision. Reporting time. At the end of your note, you're still going to document a clinically appropriate history and exam. You're going to have an assessment and a plan of care, and it has to be clear that it meets medical necessity. But when reporting time, itemize the time spent and issue a time statement in your note before you sign it, an attestation statement. This encounter took 45 minutes, including taking a history, performing the exam, reviewing the CT scan, reviewing the hospital notes, counseling the patient on new diagnosis of whatever that is, formulating a plan of care, and documenting in the electronic medical record. And yes, that does count for time. Here's what's included in time. If you're using time, not medical decision-making, preparing to see the patient, reviewing tests, reviewing notes, reviewing other records, obtaining or reviewing separately obtained history, performing a medically appropriate examination or evaluation, counseling and educating the patient, family, or caregiver, ordering medications, tests, or procedures, referring and communicating with other healthcare professionals when not separately reporting them with a separate CPT code, documenting clinical information into the EHR or other health record, independently interpreting results that you do not bill separately for, and communicating results to the patient, family, or caregiver, and any care coordination that you personally do that's not reported separately. And yes, you can use time for your medical decision or medical decision-making for your split-chair visits. So what is not included is performing other services that are reported separately. So if you're performing, let's say, an intubation or event management or you're inserting a chest tube, that's excluded from time, just like it would be with critical care. Travel is not reported separately. Teaching that is not limited to discussion that is required for management of a specific patient. Teaching that is general does not count for time. Now, if you're rounding patients and you have med students or residents with you, you're teaching them as well as managing the patient. That's different. But if you're discussing the patient, that would not be considered part of that time. So let's look at the time elements for your initial hospital inpatient or observation care. Now, keep in mind this terminology has changed for 2023. That's the title of the category of code, 99221-223. Complexity of the problem is either minimal or low. Minimal are limited for data and risk is minimal or low. And time is 40 minutes. You have to meet that threshold of time. If you're 39 minutes, you can't bill for it. It would be subsequent hospital. If it's 50 minutes, it would be 99221. If you're at 76 minutes, it's still 99223. So 223, the complexity is high with extensive data and risk. And keep in mind, two of three of those elements have to be met on that table that you saw in the slide earlier. Subsequent hospital or observation care, 99231-233. For time, we're looking at a minimum of 25 minutes, 35 minutes for 232. Again, if you have 33 minutes, you're still at 99231. And if you're at 40 minutes, you're not quite to 99233. You have to be at 50 minutes plus to bill 99223. And again, for your two of three on the medical decision-making table or what we call the MDM table that you saw in a few slides back is what you will use. For consultations, these are inpatient hospital consultations or observation consultations, 99252-255, 99251 has been deleted for 2023. Medicare and many commercial payers no longer pay for consultations, and they would want you to use the hospital care codes, 99221-223. Again, time has to be exact to bill for these codes if you're using time. And the complexity amount of data and risk is based on what level it is, and two of three on that table must be met. And as you can see, the emergency department visits, 99282-285, 99281 does not require a physician, so that one really isn't applicable to physician services. It's more nursing, maybe to ring the stitches or something minor that might be done in the ED. But 99282-285 is based on medical decision-making only, based on the medical decision-making table. We also have prolonged service codes if you go beyond the time element. 99418 is a CPT code that can be used with the highest level, 99223-233, 236. Your 99255, your inpatient consultations, at the highest level, and that means that you've spent an additional 15 minutes beyond what the time element is, and you can only use a prolonged service code if you're using time to determine medical decision-making. Medicare does not use 99418. They want us to use G0316, and you have to have at least 102 minutes for your highest level 99223 or 99233. Consultations aren't allowed with Medicare, so that's not applicable. If you don't meet that 102-minute threshold, you cannot bill G0316 in addition to a 99223 or 233. So, you're going to be using these very rarely. So, with the new hospital care E&M guidelines that are non-critical care, your inpatient hospital and subsequent hospital care codes, 99221-99233, I know I went through that very quickly. Normally, I do a session of at least two and a half to three hours on this with lots of examples so you can get accustomed to it. I do recommend that if you've not seen patients in your office, the office visit codes have been using these guidelines since 2021. If you've not seen patients in the office and you're not using these codes currently or the guidelines currently, I recommend that you attend more workshops and training to get a good understanding. It will take you a good six months to learn this, and maybe even a year. Some practitioners are still struggling in the office, on the office site with these guidelines. So, it will take you a little while to get adjusted, so don't get discouraged. CMS has periodic webinars on this topic, the E&M 2023 guidelines for hospital. If they offer it, take them up on it if you can. Sometimes they have recordings you can listen to. They have FAQs on your website. So know who your Medicare contractor is and connect with that website and follow along with it for any changes that may occur. So some of the takeaways for critical care. If critical care time crosses midnight, it's accrued until service is no longer continuous. Once it's non-continuous on the next date of service and you see them again, it starts over again with day one, day two. So day one, you see a patient from 11 to 1.30 on one date, and then return to another patient for an hour, and then you're going to bill 99291 and 99292, then you start over again for day two with 99291. So if it's continuous until it stops, the time is continuous, you bill the date of service where the critical care began. Then when it's non-continuous, if you see them again on that same date, that next date of service, you would bill again with 99291. If you're managing multiple conditions with the same patient concurrently, so providers who are managing multiple conditions can claim critical care time if it's medically necessary and non-duplicative. Practitioners in the same group and specialty can aggregate their time to cross the threshold of 99291, which is minimum of 30 minutes to 74 minutes. And critical care is eligible for split shared visits. The billing goes to the provider who is credited with more than 50% of the time spent. So who spends the most time gets credit and bills for it and co-signs off on the medical record for that date of service. If a patient is seen early on with an E&M service on the same day, and then they require critical care services, both services can be reported if they're medically necessary. Of course, you're going to append modifier 25 on the critical care service, which comes second. A different diagnosis is typically required because the condition changed. And if it's not duplicative services, both may be billed. Critical care can be paid in addition to a procedure with a global surgical period. And a global surgical period is either 0, 10, or 90 days. Your minor bedside procedures are either 0 or 10. Your major procedures are typically the ones that you're going into the OR. As long as the critical care is unrelated to the procedure, you can bill critical care. If it's related to the procedure and requires full attention of the physician, and if the critical care is above and beyond the scope of general surgical procedures performed, CMS does reserve the right to consider discounting one of the services if you have related critical care time. If you're billing critical care and you performed a procedure and you feel that it's not related to the critical care, there's a high probability that Medicare, if it's a Medicare patient or even a commercial patient, you will be audited to validate that it is distinct and separate and should be paid separately. And CMS defines documentation necessary to get credit for critical care time. Total time, not the range or threshold was met. You have to document total time. You can document start and stop time if you want, but it has to be clear that the service was furnished at the specific timeframe. And there has to be evidence that care was medically reasonable and necessary, and the role that each practitioner plays is required. We really didn't have time for questions, so any question that was submitted in the question box will be answered and will be posted on the SCCM website, so you'll have access to that at a later date. Thank you for attending Coding for Critical Care in 2023. I hope this was beneficial. And again, I would recommend for your hospital care coding that this is just the first step in learning the medical decision-making and time requirements for your hospital non-critical care coding. Again, thank you very much. I would like to thank our speaker, Debra, and our audience for attending. As a reminder, there is no CE credit associated with this webcast. So thank you for joining us. This concludes today's presentation.

billing

documentation

critical care services

2022

medical necessity

high complexity decision-making

vital organ failure

time-based billing

CPT codes

split-shared visits

global period

medical decision-making

2023

prolonged service codes

Billing and Documentation