Hello there. My name is Dave Carpenter. Welcome to today's webcast on billing and documentation update. I'm the co-director for quality and patient safety at Emory Critical Care Center in Atlanta. I'm also a PA working in the ICU. This recording will be available about five to seven days after the end of the webcast, so you can log into your My SCCM and go to your My Learning tab to access it. Before we get started, just a few housekeeping tips. We'll do a Q&A at the end of the session. To submit a question during the presentation, just type it into the question box, which is located in your control panel. And then finally, the presentation is for educational purposes only. It's intended to represent an approach, view, or statement of the presenter. The views and opinions expressed here do not necessarily reflect the opinions of SCCM. And with that, let me introduce Debra Greiner. Debra is a senior health care consultant at Karen Zuko and Associates in Chicago, Illinois. And I'll turn things over to her now. Thank you, David, for that introduction. I'm Debra Greiner. I'm a health care consultant with Karen Zuko and Associates. And today we're going to be talking about some critical care and some critical care updates. There aren't a lot of coding changes. There are some final rule issues with the CMS Medicare Physician Fee Schedule final rule that we're going to talk about. But we are going to go over adult critical care, pediatric critical care, advanced practice providers and what services they provide, direct billing, and split shared visits, which is the change for 2024, or not necessarily a change, but more clarity. And then we're going to look at some critical care examples. So let's go ahead and get started. There's a lot of information to cover. Okay. So first of all, let's talk about medical necessity. That's the most important part of any patient practitioner encounter is that medical necessity is a legal doctrine that's related to activities that must be reasonable, necessary, medically appropriate, determined by credible scientific evidence, recognized by the medical community. And, of course, the Physician Specialty Society recommendations are taken into consideration. Medical necessity is not qualified using a point system and determining the level of service or medical necessity involves factors that include involved factors from patient to patient on a daily basis. And it's determined through vital factors for medical necessity. And according to the Centers for Medicare and Medicaid Services, CMS, and they have had this published for many, many years, and it is in Publication 100-4, Chapter 12, Section 30.6.1B. And the overarching criterion for payment, in addition to the individual requirement of a CPT code, so medical necessity is the overarching criterion. And it's not medically necessary or appropriate to bill a higher level of a service when a lower level is warranted. They look at all documentation for medical necessity to make sure it makes sense and it is appropriate. It's based on things like clinical standards, clinical judgment, standards of practice, why is the patient here to be seen, any exacerbations or onset of medical conditions. And looking at what justifies medical necessity, things such as acute cardiac complications, acute respiratory distress, air embolism, cardiogenic shock, shock due to anesthesia. These are just some examples. And they encompass both treatment of vital organ failure and prevention of further life-threatening deterioration of the patient's condition. So although critical care can be delivered in a moment of crisis or being called to the patient's bedside emergently, this is not a requirement for reporting or providing critical care services. So supporting your documentation for medical necessity, some of the questions that you should answer is, does the documentation indicate a patient assessment and providers of services was provided to support vital system function? Does the documentation support that the provider was either at the bedside or immediately available? And then any family discussions can be considered if the patient's unable to participate in providing that history or discussions related to support or determine medical necessity for the treatment. You cannot count the time for critical care services or count the critical care services if you are just giving the family an update. If they are providing information that's valuable to you to manage the patient, then it can be supported. And you must have this documented in the medical record. So let's look at the definition of critical care services. Critical care is a direct delivery via physician or other qualified health professional. Now, in this context, this is a CPT definition. Other qualified healthcare professional in the area of critical care is a PA, nurse practitioner, clinical nurse specialist, somebody who can manage care for a critically ill or critically injured patient with a high probability where it might impair one or more vital organ systems or imminent or life-threatening deterioration. And that's important to be able to validate that in the medical record. So critical care involves high complex decision-making to support vital system function, manipulate, assess, treat either single or multiple vital organ system failures, or prevent further life-threatening deterioration of the patient's condition. So as you can see, some examples here, these are just examples, central nervous system failure, circulatory failure, renal shock, hepatic failure, metabolic or respiratory failure. In many cases, it does involve interpretation of physiologic parameters or advanced technologies, but it also may be provided in life-threatening situations, even if those elements are not present. And the adult critical care codes 99291 to 99292 are reported for patients who have completed their fifth year, so six years or older, up through the end of life. Critical care can be provided on multiple days, even though there are no changes made, but the treatment of the condition has to still meet that level of attention necessary. So if you're rounding on a patient and they're stable, but still critical, you might not be able to bill a critical care service. It might be a subsequent hospital care, 99231 to 233, if they do not require that higher level of care. And that's why it's so important that good documentation is important. If you have a patient who is critically ill or injured, and they're here for postoperative care, if it's unrelated to the postoperative care, it can be billed for. But if it is related, it is considered part of the global package and not reported separately. So, critical care is usually performed in a critical care area, a neuroscience unit, coronary care unit, intensive care. It can be provided in any setting, respiratory care unit, emergency department, et cetera. It's the status of the patient that's important. So when we're looking at the codes, they're based on time. So our adult critical care codes are based on time. If it's less than 30 minutes, you would not bill critical care. You spent less than 30 minutes for that total date of service. So you can accumulate the times that you spend managing the critical portion of the patient's care through that date of service. But if it's less than 30 minutes, you report probably if it's your initial visit, the 99221-223, or if it's a subsequent care code, 231-233. 30 to 74 minutes, you have to meet that threshold of 74 minutes in order to move to 99292, which is the add-on code for each additional 30 minutes. And therefore, and so forth. So for patients in the ICU, sometimes patients are put into the ICU for various reasons. If they're not in the ICU and do not meet the definition of critical care, you do not use critical care codes. If you're within the global period and you're the surgeon who's managing the critical care portion of that postoperative care, you're the surgeon, you would not bill critical care. When it does not equal or exceed 30 minutes, it would be typically the initial or subsequent hospital care code. And if the patient doesn't meet the definition, even though they're in the critical care unit, they're no longer critical or you're not managing the critical portion, that would be a subsequent hospital care code. And patients in palliative care, and I've gotten this question many times, this is not critical care. Palliative care is not considered critical care and should not be reported separately. So what can be included in critical care? Providing the services to the patient's bedside, discussing the patient's condition with other physicians or members of the team, the care team. When you're on the unit and immediately available to the patient, reviewing data related to the patient, performing procedures that are bundled into critical care. If it's bundled into part of that critical care code, which we'll talk about in a moment, it is considered part of that time. Discussions with the family, as I said earlier, if it involves obtaining a clinically relevant history. And you should summarize in the medical record what that history was and who provided it and why, to make it clear if you're ever audited by a payer. And writing notes in the chart when you're on the unit and immediately available. That is included in that critical care time. Things that are not included, including updating family members, can't even say it, teaching time, time spent off the unit, time spent caring for other patients, time spent on telephone calls, any activity that does not contribute to the treatment of that patient. Any procedures that you perform that you could separately report a CPT code, that is excluded from that time. It should be documented as such. And time spent in typical follow-up for all patients. And treating complications, complications unless the patient goes back to the OR in the post-op period is included in that global package and not reported separately. Services that can be included, we talked about that in the calculation. I'm going backwards here. Okay, services included in critical care. Now, this is part of the critical care time. Interpreting cardiac output measurements, chest x-rays, pulse oximetry, blood gases, any physiologic data like blood pressure, EKG, hematologic data, gastric intubation is included, temporary transcutaneous pacing, TTP, ventilator management, that is included in critical care. And one thing to share is just because a patient is on event doesn't mean they meet the definition of critical care. If they're stable, they may not meet that definition. And peripheral vascular access, those are all considered. And you can see here on the slide that I've got the codes listed that are included in critical care. So that time that you perform these procedures, you count that time. Here are some examples, just examples, not all inclusive of services that can be built separately, such as swan scan catheters. CPR 92950 is excluded from critical care. So you can bill for that separately. Central line, chest tube insertion, endotracheal intubation, for example. So these are some of the things that can be built separately. So when you document, document your critical care time, the total time for critical care. If you want to use start and stop times, you can. It's not required by most payers. And then make a note of the actual time that was excluded from critical care performing the procedure. So what's included? What needs to happen with critical care? You have to have full attention of the practitioner, whether it be a physician or advanced practice provider. During the time that you're providing critical care to this patient, you cannot give attention to anyone else. So if you're spending 30 minutes managing a critical patient, maybe after a car accident, they're in the ICU, you're managing their care. You must be also immediately available. At the bedside or elsewhere on the unit. So time includes ordering or reviewing lab test results, discussing the patient with other practitioners. That includes nursing staff, even if it doesn't occur at the bedside. So that time is counted as long as you're managing the care of that patient. So time spent off the unit is not counted like telephone calls. I have a, I had a practitioner who was a critical care intensivist and he had a patient in the emergency department who had a very horrific car accident. And he was managing the care in his home because he was called in the middle of the night. That is not considered managing critical care. Because it is off the unit, so it could not be reported. So critical care for Medicare, as far as time reporting, this was part of the 2023 Medicare Physician Fee Schedule final rule. And this is where they emphasize, and that was this year, that you can only use critical care services, 99291, which is the 30 to 74 minutes once per day per group. Even if it's not continuous. So, if you have, let's say, a nurse practitioner or a PA who is working in your group. You all have to accumulate your time together. If you have two, let's say, two critical care intensivists working together in the same group, and you're managing that patient on that date. That time does not have to be continuous, but only one practitioner would bill for that and used only once per day. So, after the practitioner has spent 140 minutes providing critical care, that would be when 99292 is allowed. Now, this differs from CPT guidelines, because once you hit that 75th minute, 99292 is allowed, but for Medicare to bill 99292, you have to accumulate 104 minutes. And that includes split shared time or split shared services, which I'll talk about in a bit. So, total time can be aggravated by the same specialty in the same group. If you have a cardiologist and a pulmonologist, both managing portions of critical care, there are different specialties, different taxonomy codes, even though they might be in the same group, they would be different. They would not be one in the same. So, the advanced practice providers, and there's been a lot of controversy over this throughout the years, but the rule is that if you have an advanced practice provider in your same specialty or subspecialty in your group, the advanced practice providers now have a different taxonomy and specialty code for Medicare. But if they're working in your group, they are considered one in the same, and they actually revised these guidelines for the hospital services in 2023, and they have actually updated that in 2024 to validate that if you're in the same group with the same specialty, you are considered part of that as an advanced practice provider. An APP can provide concurrent follow-up care subsequent to the practitioner's critical care visit. It can be continuous or follow-up care on the same day, and it can be aggregated to meet the requirements of the 99291 30 to 74 minutes. So, here's an example where the physician sees a critically ill patient 45 minutes. Later in the day, the PA manages the patient in critical care for 34 minutes. You have a total of 79 minutes, 45 and 34. You would only bill 99291 for Medicare because, again, 99292 would not be reported unless you met that 30-minute threshold of 104 minutes. I know that's not fair, but that's Medicare's rule for critical care services. So, different specialties. If you are a different specialty, so you've got pulmonology and cardiology as an example, and you're both meeting the definition of critical care for managing that problem, you can both bill the critical care services as long as they are duplicative. They have to be medically necessary. They have to be non-duplicative. So, you have a cardiologist managing a myocardial infarction, 66 minutes, and then the pulmonologist managing the pulmonary embolism, 45 minutes. The cardiologist would report 99291. Pulmonologist would report 99291. You would not need a modifier because they're different specialties, even if in the same group legally. Care is not always critical because if you aren't doing any interventions and the patient is stable, I have one example where somebody asked me once, they billed critical care where the patient was sitting in the chair reading the newspaper in the critical care unit. They had been critical. They're getting better. They're stable. That would be a subsequent visit, and that would not be critical care. And that would not be critical care. And subsequent visit codes, 99231 to 233, now they're called subsequent or observation services. That would be based on either medical necessity or time and billed only once per day. Critical care can be reported on the same day as an evaluation and management service if it meets the criteria. So if you have, and we're talking about an E&M visit, let's say 99231 to 233, and the patient becomes critical later in the day, you have to be able to validate that with your diagnosis codes and your documentation. So you need to explain that the patient was stable at this point, and now they're critical, and you had to move them to the critical care unit or whatever, wherever you're taking them if you're moving them. So it has to be medically necessary, and we would report modifier 25 on the second procedure. So if we bill, let's say, a 99233 in the morning, in the afternoon the patient becomes critical, we bill a 99291 based on time, depending on time. We use modifier 25 on the critical care service to say it was significantly separately identifiable, and our diagnosis codes will support that. And modifier 25, if you didn't know, is actually one of the most, between modifier 59, 25 is the second most modifier that we've seen in a while, and payers are actually building their own policies that are not CPT's definition. So here's an example. We have a patient admitted as an inpatient with chest pain, shortness of breath. Cardiologist does that initial inpatient visit. Later in the day, the patient's crashing. Cardiologist comes to the bedside. They had an acute MI. They're transferred to critical care. The physician spends 45 minutes stabilizing the patient. So we would bill the 99291 with the 25 modifier for the first 30 to 74 minutes, and 99223 for the initial patient visit, even if it's on the same date of service. If critical care continues to the next day, if it continues to the next day, if it's after midnight and you are managing a patient continuously, that time should be accrued and reported as occurred on the previous midnight date. So if on December 10th, 2023, you're managing a patient at 10 a.m. or 10 p.m., and you are continuously managing that critical portion, whether at the bedside or managing that patient with full attention, and it's now 1210, you would report that entire time that you spent that was continuous as the date of service when the critical care began. So one thing that you need to make sure that you document is that the circumstances related to the continuous service. So here's an example. Patient admitted to neural ICU, motor vehicle accident, closed-end injury at 1115. Critical care physician provides intervention from 1115 to 1245 a.m. on 1116. It would be billed on 1115. And that would be the 99291, 45 minutes. It depends on the timeframe, but in this instance, if it was not Medicare, it's 90 minutes. So we would add the 99292 after the 74th minute. Okay, if this was a Medicare patient, it would only be 99291 because you have to meet that threshold of 104 minutes before you can bill 99292. If it's a non-Medicare patient, most payers will pay for 99292 at minute 75. Okay, so a brain-dead patient. Can you bill critical care for a brain-dead patient? No. You would bill the discharge code on the date of discharge, 99238, for less than 30 minutes. If it's more than 30 minutes for a discharge, and that includes the H&P, that includes documenting in the EHR. Everything that you have to do to discharge that patient counts. 99239 is over 30 minutes. One of the biggest mistakes I see when I audit records, and I audit thousands of records a year, and one of the biggest things I see with discharges is not documenting the total time. As a critical care intensivist, you're well aware that time is important, so I'm sure that you're documenting that time. If you have a brain-dead patient, you have to declare them, and then you have to document. One thing that I didn't mention about when critical care continues to the next day, and I want to backtrack for a minute. If critical care continues to the next day, and it was continuous, you bill the date that it started, the critical care was initiated. If it's noncontinuous, so let's say at 1210, your management of that patient at that time is over. You come back in, let's say, at 12 o'clock p.m., and the patient is still critical. You're still managing the critical portion. Then it would start over again, so the 99291 for the first 30 to 74 minutes would start over. Okay, let's talk about the advanced practice providers, and those include your physician assistants, nurse practitioners, and clinical nurse specialists. Medicare calls them NPPs, the industry calls them APPs, and CPT, the AMA, calls the advanced practice providers other qualified health professionals. I wish we would really just all come together and come up with one acronym for these professionals, and if you're one of them, I'm sure you feel that because it is all over the board. So let's talk about split-shared. A service performed by both the physician and advanced practice provider is considered a split-shared service on the same date, and with critical care, adult critical care, it is time-based, so it would be based on time by both the physician and the advanced practice provider who are in the same group of the same specialty. So if you have a pulmonology critical care intensivist and the advanced practice provider who's a pulmonology critical care intensivist, and you have the cardiology physician, they are different, so they are not in the same group, same specialty. They're in the same group, maybe, but not the same specialty. And then looking at the facility setting, now split-shared can only be performed in the facility setting, and that was actually validated in the final rule. Under this regulation, it's allowed for hospital E&M services and that includes critical care and your pediatric critical care and skilled nursing facility. In the office setting, it is not allowed. So the AMA has updated for 2024 the definition of split-shared, which I'm showing you here on the screen. It's where a physician and other QHP, which is other qualified health professional, both provide a portion of the face-to-face and non-face-to-face work related to the visit. A split-shared visit can either be based on medical decision-making if it's a hospital visit. If it's a critical care visit, it's based on time. And that includes assessing and managing the patient, counseling, educating, communicating results to the patient, the family, the caregiver on the date of the encounter. If it's based on time, the time is for that date of service. And it could be summed for split or shared visits. Now, how do you bill for that? Here's the key. When you're billing for your split-shared services, whoever spends over 50%, and I'll talk about that in a minute, from a CPT perspective, if that practitioner spends at least 50% over and above, whether it's medical decision-making for your hospital visits, subsequent hospital or initial hospital, or time-based for critical care services, they bill for that service, whether it be the physician or the advanced practice provider. If the code level is selected using time, whoever spends the majority of time bills for the service. If medical decision-making is used, whoever is responsible for approving the care plan for the problems addressed and takes responsibility for managing the risks for the substantial portion claims the level of service. So if you have a 99232 that you're billing, whoever does the most work, approves the care plan, takes credit for the visit. And this includes all your hospital services, 99221 to 223 if you're using medical decision-making. If you're using time, it's 50%. So Medicare uses a little bit terminology. They say more than half of the total time. Well, 100%, 50%, that's more than half. Split share does not apply in the office setting for your advanced practice providers. It is not allowed. Modifier FS must be appended to split shared services. Whoever bills for it and whoever bills for it has to sign the note. Now, it's really a good idea for both practitioners to sign the note, but whoever electronically signs that note bills for critical care. So to qualify for a split shared visit, the APP and the physician must be in the same group, same specialty, working jointly, related to the patient's encounter to furnish care. They must see the patient at different times, not together to count the time. So if you're seeing the patient together jointly, only one person gets credit for the time. If you see the patient as a physician in the morning and then later in the early afternoon, the advanced practice provider sees the patient, then both of you can count that time and aggregate it. If the physician and APP are in different specialties, each would bill his or her own services independently. And again, for physician payment, for Medicare, it's 100% of the allowed amount. For your advanced practice providers, it's 85%. So it's more advantageous that the practitioner, the physician spend more time, at least 50% if using time for the critical care split shared services in order to bill for it. And reap the 100% allowable for Medicare. And you must meet that substantive portion. So the 50% for time or medical decision-making, whoever approves the plan of care and the complexity of the problems and risk would bill for it. Documentation has to identify the practitioner who performed the visit. And again, just as a reminder, do not forget that FS modifier split or shared in the hospital setting, whether it be subsequent hospital, initial hospital or critical care services, it must be used. So here's an example of split share. The cardiologist is managing a patient, an acute MI, patient's worsening, physician spends 45 minutes. The APP comes in later in the day and spends 30 minutes. 99231 would be billed for the 75 minutes. If it's Medicare, and the physician would bill for it because it's a substantive portion of the visit. Now, again, you've gone 75 minutes. So if it's non-Medicare, you could add the 99292, the add-on code. But the advanced practice provider would not bill, it would be the physician because they spent most time, most of the time. So the global surgical package, I know I'm going pretty fast, but I've got a lot of information to cover. The global surgical package includes a patient who is critical postoperatively. It is unless it's unrelated to the surgery. So you've got an example here where the physician or the partner of the same specialty repairs a lacerated liver after trauma. You manage the other injuries, such as a hemothorax in the ICU for 40 minutes. So we could bill a 99291. Now the FT modifier says that the critical care service is unrelated. So the hemothorax, the other injuries, aren't related to the reason that we perform the repair of the liver during the trauma. So modifier 52FT, the definition is unrelated E&M during a postoperative period. And that includes when you're seeing a patient in critical care, and it will allow separate payment. Now, just keep in mind though, make sure it's clear that it's unrelated. You have a different diagnosis and you're managing problems that are not related to the surgery, because payers are watching modifier FT, they're watching billing critical care services by the surgeon during the global period. If they're critical by nature, postoperatively, that's not considered appropriate to count that separately and bill critical care. So if it's directly related to the surgery performed, it's not appropriate. Here's an example where the patient becomes hypertensive after abdominal surgery due to hemorrhaging at the surgical site. Physician manages a patient during the post-op period following a whipple after blood abdominal trauma. You manage the fluid and nutritional needs and monitor for complications, that's included. And you manage the patient postoperatively in the surgical ICU, monitoring vital signs, metabolic status, because the patient has comorbidities and increase the likelihood of complications. That is not considered outside of the global period. And you have to understand that when the RVUs are being calculated, they are adding for some of these complex cases, certain critical care days into that. Again, if the encounter is unrelated and payers do expect a different diagnosis code, and they may request documentation to support medical necessity. And I would say that in many cases, they do. So what needs to be documented for critical care services? Some basic information, we need to know why are they critical? And that's a good question. So what are the critical care services? So why are they critical? And that's one of the things when I audit critical care services, sometimes it's unclear. Why are they critical? If you say the patient is stable, you're not telling me they're critical. You can tell me they're stable, but critical. So why are they considered critical? Any history, including any prior medical history, meds, lab findings, vital signs, data needs to be documented. A well-documented exam. Now, not every time you see the patient, you have to document a complete exam, no. But just make sure that your exam is clear. Any diagnostic tests that you ordered or reviewed and document that you reviewed those. Any interventions, a detailed assessment and plan of care. Don't say continue same plan. There's no detail there. And documenting time. Do not use a blanket statement, the specific time spent for critical care services for each encounter. And then sum those up. So let's look at some documentation. Is it good or bad? Some is good, some is bad. So we have a 75 year old woman, type two diabetes, on metformin. Comes in with cholecystitis, bilirubin is increasing. Liver function tests have improved with antibiotics. She has an elevated troponin level. Episode of abdominal pain subsequently is found to have ST changes. What supports critical care? In that documentation, I can't find anything that would support it with a payer. Okay, here's another one. And these are real notes. She's awake alert and no oxygen. Chest is clear, no murmur. Abdomen soft, extremities not edematous. Cholecystitis, waiting for less inflammation will probably have two placed. Multiple medical problems will follow glucose. Doesn't support critical care. And this was actually billed 37 minutes critical care time, including discussions with APP and patient, chart review and physical exam. It was billed as a 993-91. Would not support it. Here's another one. Patient remains critical due to need for ongoing intensive neuromonitoring, cardiopulmonary monitoring and respiratory monitoring and support. I spent 102 minutes providing critical care. What was done? The patient's plan was discussed in detail with the multidisciplinary team. What is that plan? You have to document what that plan is. We don't know why they're there. There's no assessment and plan and no documentation of interventions. These are real notes from critical care services. And this one was billed as a 992-91 and 992-92. Okay, so documentation. What should it include? It should always tell you, first of all, why is the patient critical? What's the rationale behind the patient being critical? Is there an organ system at risk or interventions that need to take place, including diagnostic or therapeutic and what's the rationale behind that? Any critical findings, your lab tests, imaging, EKGs, what's their significance? What's the plan of care? And make that a detailed plan of care. And what is the likelihood of life-threatening deterioration without intervention? And for adult critical care, the total time spent. These are just simple things, bullet points that you can add to your documentation if it's not complete to make sure that you dot your I's and cross your T's because critical care has been on the OIG work plan for a while. Looking at critical care services, there have been reports that have been written about practices or groups that have not been providing the documentation necessary. So to improve your documentation, provide specific examples of potential or actual organ system failure, hemodynamically instability, mental status alteration, any multiple data reviewed, monitoring, complex decision-making. Here's an example. Patient with head injury and loss of consciousness requires frequent neurologic monitoring and data review. Patient with acute stroke and hemiplegia requires neurologic monitoring, imaging, and data review, as well as urgent coordination with multiple specialists. That can help improve, okay, now this makes sense why this patient is considered critical. Let's look at this scenario. We've got a patient with septic shock. They've had their initial treatment. It involves intubation, placing a central line arterial line. They have had their own event, volume resuscitation, antibiotics, and infusion, titrated. They've had an EKG arterial blood gas measurement. Central venous oxygen saturation determination, chest radiography interpretation, time spent in critical care, as well as the ICU admission was 119 minutes with 45 minutes devoted to procedures. And that would be the procedures that could be built separately. So we're going to build a critical care time is 119 minutes and minus with the 45 minutes for the procedures because those were considered inclusive. So that equals 74 minutes minus the 45 minutes. So we had 119 minutes, 45 minutes for the procedures, the procedures we build separately. So we have 74 minutes of critical care. The easiest way to do it is total time for critical care, 74 minutes, total time for procedures, 45 minutes, and let the payer look at it and they can make that determination. So we would bill a 99291 with a modifier 25. Now you always bill a modifier 25 when you are doing procedures that you're billing separately for as being significantly separately identifiable. So we did an intubation, 31500. We did a central venous catheter, 36556. That's 51 modifier. It's not bundled, so we don't need a 59. And we did an arterial catheterization. We put in arterial line 36620. So we would fill an E&M with a 25 that says we did critical care plus we perform these procedures. Now we have a 65-year-old patient, motor vehicle accident, in the emergency department, fractured pelvis, oblique from the spleen. General surgeon comes in and consults. Patient is hypotensive, but they respond to the fluid challenge and accept all vital signs. The surgeon inserts a central venous catheter because they have a poor IV access. Surgeon then evaluates the patient with trauma life support, a survey. Contrast CT of the abdomen and pelvis with blood, urine, and EKG test. They have pain on pelvic palpation, suspecting a pelvic fracture, and the surgeon performs a focused assessment with sonography in trauma, a fast exam with image. So it shows that the patient has blood around the spleen, no free fluid. They are considered critical. They admit the patient to the ICU. The surgeon sees the patient later in the evening. Patient's stable, requires no vasopressors or operation, but does require a transfusion and adjusting pain meds. And they're subsequently moved after they remain stable to a rehab facility after a seven-day hospital stay. So in this scenario, the physician documents that they were in direct attendance with the patient for 120 minutes. And the emergency department, excluding the procedure time, including care coordination and communication. So in this instance, the procedures that we would report would be an E&M service 99291, modifier 25, 99292 with two units. And that would be for each 30 to 74 minutes, 99292 is an add-on code. And then our central line insertion, 36556. Again, that modifier 25 is necessary. We spent 120 minutes. This is not listed as a Medicare patient, so we can bill for the additional time with 99292. We'd also bill for the ultrasonic guidance. And since we are in the hospital setting, we always use modifier 26, which says professional service. So that means a professional component. You're looking at the ultrasound and you don't own the equipment, so you're not gonna bill for the technical. And then the abdominal ultrasound, the retroperitoneal ultrasound, the chest ultrasound, all of those would be billed separately with the 26 modifier. And so this would include reviewing the nursing notes, reviewing medications, allergies, vital signs, documentation time, care transfer, ordering, interpreting, reviewing, obtaining history from the family, the nursing staff, or the treating physicians, whoever you have to obtain it from. And the physician documents, my critical care time did not include time spent teaching resident physicians or other services of resident physicians are performing reportable procedures. So they have documented here the total critical care time, 45 minutes. So you have to actually break it out and explain what is your critical care time and what does it exclude? So in this procedure, it doesn't give us that specific documentation of what was critical for this patient. Even though we can assume the patient was, you need to tell us that in the documentation. So now we have a 14-year-old boy without a helmet, unhelmeted passenger and an ATV rolled over, unresponsive. EMS intubated the patient. In the emergency department, he's stable. The Glasgow Coma Scale is 6T. We did chest X-rays, endotracheal tube placement. This is a trauma patient. He has a CT. He's stable with no change in neurologic status. Shows that he has a hemorrhage, compressed ventricles and basal cistern and basilar skull fracture. Neurosurgery emergently places the intracranial pressure monitor and transfer to the pediatric ICU. A central venous line is put in. Now this is a 14-year-old boy, so the critical care would be considered time-based. That was managed. Care plan and progress notes discussed. Critical care time, 45 minutes. So later in the evening, the covering partner, same specialty is called in because the pressure is elevated and it's not responding to medical therapy. So neurosurgery then performs an urgent craniectomy. So the plan was discussed with the family. The time the physician, the neurosurgeon spent with that patient managing the critical portion before taking them to the OR is counted. So we have a total of 45 minutes for the first practitioners, 25 minutes for the second practitioner. So that would be a total of 70 minutes. So we would bill this as 99291 for physician one. For physician two, they did not provide more than 74 minutes. And most payers would say that is not enough time to exceed. So you can only bill that as 99291. Medicare is a minimum of 104 minutes. Okay, let's look at this scenario where we have a 45-year-old woman admitted to the ICU. They had pre-flap surgery by the plastic surgery team. Orders placed, the flap was checked hourly. The patient was hemodynamically stable and the care plan discussed with the patient. Time, 30 minutes. Is this critical care? No, this is a post-op patient in the critical care unit. And they did not meet the criteria for critical care. So this would be, if it's the plastic surgery team seeing the patient post-operatively, it's included in the global package and not billed separately. Now we have an 80-year-old patient who was admitted to the ICU. 80-year-old patient admitted to the ICU after a laparotomy for perforated colon, documented the past history. She was intubated, unstable hemodynamically. Okay, so now we're critical. We've got our blood pressure. We've got our central venous pressure. Care plan was discussed with the family. The family has informed the patient is critically ill and her prognosis is poor. So we spent 30 minutes managing the critical care. In the evening, you're called urgently to the bedside. The patient is bradycardic. 25 minutes is spent. They lose pulse and the team begins CPR. Advanced cardiac life support is followed by 20 minutes. No return of spontaneous circulation and the patient passes away. So for the first 30 plus 25 minutes, that's 55 minutes that we're providing critical care, we would bill that critical care services. So going back to this, so the patient was, we spent 25 minutes previous. In the early evening, we initially spent 30 minutes. Then we spent 25 minutes and that's when the critical care time stopped because CPR begins. And remember I said CPR is excluded from critical care. You can bill for that separately. And the patient passes away. So we would bill 99291 for 55 minutes total. Time spent with the family after death is not separately reported. It's not included in critical care time. So let's turn to the neonatal and pediatric critical care codes. These are not time-based. These are based on category of service and they're based on total date of service. So these are 99468 to 76 is neonatal pediatric for the initial and we have our subsequent through 28 days. Our infants and young children 99471 to 76 based on the patient's age and the initial hospital care is reported only once per admission. Subsequent hospital care is codes for DM per day. Only one physician specialty in the same group no matter how many physicians of the same specialty manage the patient. And yes, you can split share in the pediatric critical care because it's only billed once per day. Either based on, we're not basing these on time. We're basing these on either time or medical decision-making. So if the same physician in the same group provides outpatient and inpatient critical care, it's based on age. And if they are providing critical care at one facility, and they're transported to another, then it would be based on time. So, if critical care is performed in the outpatient setting, the office emergency department, outpatient hospital, any unit where the patient has not been formally admitted, it's time-based, whether they're, no matter what age they are, it would be time-based. If they see the patient and they're in pediatric critical care or neonate status, it would be 99468 to 99476 based on age. Okay, can a neonate or pediatric intensive care service be shared? Yes. So, here's an example. An APP works on the medicine service rounds on a hospital inpatient in the morning, documents a visit in the chart. Later the same day, the attending physician has a face-to-face with the patient, reviews the advanced practitioner's note, documents the interval history, and confirms the plan of care. Whoever provided the most substantive portion bills for it, but not both. Only one provider may be billed, not both. The attending physician, if they approved or formulated the plan of care, then it's more likely they'll bill for it. So, here are codes 9946869 and 77. These are our neonate codes. The initial is 99468. The per day subsequent inpatient neonates 99469. And for the 28 days or younger, that requires intensive observation, frequent interventions, and other intense care services, 99477. These are our neonatal critical care and low birth weight patients. So, here's an example where we have a term infant born after a normal pregnancy with delivery. They're in respiratory distress, require a neonatal ICU admission and intubation. A neonatologist places an umbilical arterial line, chest radiographs, pneumothorax. Neonatologist places a chest tube. We would bill separately for our procedures that are not included in pediatric critical care with a modifier 25, so 99468. And then our two thoracostomy, the intubation, the catheterization, the umbilical artery, arterial line. And again, we need modifier 25. Now, these are our low birth weight neonates, 9947879 and 80, and they're based on current body weight. And these are per day. They are not based on time. They are per day. And then we have our transport codes, 99466 and 67, and these are based on time. First, 30 to 74 minutes is 99466, 99467 is for each additional 30 minutes. Our initial inpatient critical care for our peds patients that are 29 days through 2 years of age, 24 months, 99471 for the initial visit. Billed only once per admission, then our subsequent 99472 and 75 is the initial for ages 2 through 5, and 99476 is for our subsequent day. So these are based per diem per day, and only one practitioner in that same specialty, same group may report these. Here's another example. We have a 25-week gestation infant, 45 days old, on a vent. They're dependent. They've increased ventilator requirements and poor perfusion. Provider suspects acquired sepsis, performs bladder aspiration, lumbar puncture, blood cultures, and begins a course of antibiotics. So we would build the 99472 based on age. They're 25 weeks, so they would fall in this classification for the initial visit or the subsequent visit for that patient. And then we have our other services, our standby services. This is attendance for a frozen section or a C-section, a high-risk delivery, attendance at delivery if an OBGYN or a physician requires or needs attendance or assistance, 99464, our delivery birthing room resuscitation, 99465, inter-facility transport care where a physician or a practitioner needs to supervise that transport of the critically ill patient. And this is 24 months of age or younger, and you must have two-way communication with the transport team at the referring facility. And that's 99485, and it's based on the first 30 minutes, and each additional is 99486, which is the add-on code. And then this is what's bundled in the pediatric neonatal critical care, all the codes for the neonates and the critical care for the pediatric patients, peripheral vascular catheterization, arterial catheters, venous catheters, central vessel catheters. All these procedures that you see on the screen, including vet management and bedside pulmonary function testing, are included in addition to what's included in adult critical care. So there's a lot more included in your pediatric critical care per diem codes that are bundled, including continuous positive airway pressure, CAR-C evaluation, transfusion of blood components, oral or nasogastric tooth placement, lumbar puncture. So all of these are included. So some takeaways for 2024. The one thing that is critical is that if critical care time crosses midnight and it's continuous, you bill it based on the initial onset of critical care, that date of service. If it's noncontinuous and it stops, let's say, at 12, 10 a.m., you bill that initial date, the previous date of service, as your 99291 for your initial service, based on how many minutes of critical care. You could add 99292 if possible. So 11 to 130 would be 99291 plus three units of 99292 if it was not Medicare. And then with day two, it's noncontinuous. Now you see them later, and you're managing critical care. You would start all over again. Providers who are managing multiple conditions for the same patient concurrently, if it's medically necessary, the services are not duplicated, and they are not in the same specialty. So you've got cardiology, pulmonology, managing multiple conditions, and they're doing it at the same time, and that means they're managing that critical patient. You would bill those separately, as long as you're doing something other than they are. And practitioners in the same group and specialty can aggregate their time to cross the threshold of 99291. Again, for Medicare, in order to report 99292, you need 104 minutes. And for other payers, at minute 75, they will allow the add-on code. Split shared visits are allowed, modifier FS. And one thing to take away for CMS is that it's based on more than half the time spent for CPT, the AMA, in the new guidelines or in the guidelines or in the CMS Medicare Physician Fee Schedule final rule. It was more than half the time. CPT is defined time as more than 50% for split share. And if you have a same-day E&M service, as long as they are not critical when you're billing that initial hospital or subsequent care code, they later become critical. You can bill both services with modifier 25 appended to that critical care code. You can't do it vice versa. They're critical, and then they're not. That wouldn't be appropriate. But if they are not critical, become critical on the same date of service. It does support it being significantly separately identifiable. And then critical care can be paid in addition to a procedure with a global period. If it's unrelated to the procedure and you must append modifier FT and your diagnosis code must be different. And CMS does define that documentation is necessary for critical care time, total time, not a range of time. So for CMS, they want total time, not the range of time. I've seen I spent at a minimum 30 to 74 minutes managing the critical care. That is incorrect. You need to document that specific time. Do that every time and you'll be fine. And lastly, before we close today, I know we're about three minutes behind. I was asked to share these diagnoses for sepsis after care. It's important, especially if you've got a patient in critical care and they have sepsis following a procedure which would not be part of the global period. And you could build that critical care separately. The T81.44XA means the initial encounter. That is the active treatment. Sepsis following a procedure subsequent encounter. That's the healing phase. So they're getting better. And then sequela is a late effect. So they have sepsis following a procedure. That's your late effect. And we need an additional code to identify what that infection, R65.2. And then we have further characters identify severe sepsis if that's applicable. So that just gives you an insight into those three codes, T81.44X. That X, if you don't know it, is a placeholder. It doesn't have any meaning. But A means initial encounter. D means subsequent encounter, the healing phase. And S means sequela late effect. So with that said, I will turn this back over to David. Let me just do a couple. There's a couple that were just questions about the we were informed that we need to spend 105 minutes before we can build 99292. Just to reiterate what Deb said, that's if the payer is Medicare. So if the payer is not Medicare, you can bill a 99292 once you go over 74 minutes. That is correct. Yeah. There's another question basically for commercial payers. In the example you gave, could you bill a 99291 and 99292? And the answer is yes. Yes. Let's see. There's a lot of – well, let me just start with the top. So three questions for 99291, I'm assuming. Does it include teaching critical care billing on the day of transfer out of the ICU? And each half hour must be completed the half hour, which I'm not sure what that exactly means. I'm not sure what that means either. So what was the first question again? Does the 99291 include teaching? It does not include teaching unless you're managing the patient as you're teaching. And then critical care billing in the day of transfer out of the ICU. Okay. If you're transferring them out of the ICU, my question to whoever asked that question, are they stable now? And if they're stable now, they're probably not considered technically critical. Yeah. So you wouldn't be able to bill a critical care service in that case. Yeah. I mean, my reply to that is if the patient was, say, sometime after midnight was critically ill, was treated, the critical illness is resolved, then I think you could. Yes, you could in that instance. If they were critical and now later they're not critical and you're transferring them out of the ICU, that portion of critical care you manage, of course, you're going to bill for. Yeah. And this is, you know, there were a very select group of payers that were actually paying for other E&M services after a 99291. Yes. But the newest rules have made it very clear that that's actually no longer allowed. Correct. So now they're stable later in the day. You're transferring them out of the ICU to a unit. You wouldn't bill that visit. You wouldn't bill that E&M visit. And I do agree in the past some payers were paying it. And then it was clarified that, no, you can only pay it the hospital visit code if they weren't critical and now they're critical later on. Then it would be appropriate. But vice versa, it's not. Yeah. And then just to clarify, the 99291 Medicare threshold for 104 minutes is active now. Yes. We're getting reimbursed right now, unfortunately. Yes. Unfortunately, that went into effect January 1st of 23. I think it was 22, actually, wasn't it? They tried to do it in 20. It came out in actually February of 23, and then they backdated it to January. Yes, that's what they did. Yes, now that I recall. You're right, David. So for tele-ICUs, can you have bill for video, et cetera? So during the pandemic, they relaxed the rules on tele-critical care to allow you to bill the 99291 for tele-critical care. I actually honestly don't know if those rules are still in effect. Actually, they have allowed it. Critical care is still on the tele-health list, and they've actually extended the critical care allowance to 2024. So we have until December 24. What's going to happen after that? I don't know. I think they're hoping some legislation will be passed to allow critical care to become permanent in all settings. But currently, critical care, as of the Medicare fee schedule final rule came out, tele-health is still on the list. Critical care is still there. For post-op patients, can you talk about the care in the ICU that's included in the global surgical package versus not? Does it matter if the care is being provided by the surgeon who did the surgery versus an ICU MD or APP? Well, that's a really tough one. If the surgeon is providing critical care services as part of the global, and it is not unrelated, it's included in the global package. The issue becomes if you have a critical care intensivist or a hospitalist who's taking over care post-operatively, they didn't perform that procedure. If the patient is critically and they're managing it, they should bill for it. Whether or not a payer takes the money back, that's up to their policies. Yeah. I will say that it's also based upon what is normal for that surgery. Since there are very few surgeries where it's normal to have post-op respiratory failure and shock, say, for the most part, you can bill, as long as you bill it as a separately identifiable service, any of those people can bill critical care. You just have to watch. There's a few, I believe they're cardiac surgery CPTs, where the critical care is actually included in the global bundle. And that's the ones you have to watch. Right, right, right. And, yeah, you are right. There are some cardiology. They built the critical care days into the RVUs. Right. So some of those can't be built separately. Okay, let's see. Ah, sorry. Would time spent discussing care with another provider count toward critical care if the conversation was on the phone? Hmm. Well, I would say yes. Yeah. If the person that was having the conversation during the critical care time is in the ICU. Correct. That's what I was going to say. If they're in the ICU or in the unit and they're on the phone, the critical care time counts. Now, I did run into an encounter where a pulmonologist, he was a critical care intensivist, was doing research, excuse me, on a patient, and Medicare asked for the documentation, and Medicare said that research does not count for critical care. Yeah. I think that's how you, that's, you know, if you say I was researching this, the patient's care, then, you know, you're going to have a problem with that because Medicare doesn't pay for research. Right. But that's just kind of a, if you said I was discussing the patient's care with another specialist. Then that would be considered, you can bill for that time as part of critical care. So there's a lot of split-shared questions. We'll just start with this one, I guess. On a single day, if a patient receives critical care from an MD for 45 minutes, APP on the same team for 35 minutes, and a second APP on the same team for 35 minutes, which conditions receive credit for the 99291 and 99292? Oh, that's a new one. I've not heard that one before. Okay, so you've got two APPs and one MD. We actually specifically in our reply to SCCM's reply, you know, said, hey, by the way, you didn't talk about what happens when three people actually see the patient and they ignored it, so. That is true. You know, I would say that I would bill under one of them. I can't, I really don't have an answer for that because that has never been addressed by CMS or the AMA split-shared rules. They've always involved two people, but not three, but in critical care, I could see where three people would be involved. You could either add the two APPs together, or you could count each one separately, whoever spent the most time, and that's how I would do it because then the physician would probably win. Yeah, that's how our organization would do it, too. I mean, they would put all of it, you got 45 plus 70, so you have 125. Did I do the math right? 115, sorry. So you'd have a 9-1 and a 9-2 there, and we just put it all under the physician. Yeah, I would do that. Yeah. So we're in a different specialty but in the same group. Does our critical care time add up, or should it be separate? It should be separate as long as you're not managing the same, if you're managing different problems or different portions of the critical care, then both bill it separately because you're not in, you don't have the same specialty code. Yeah, the one thing I will, the caveat I will say to that is like we have mixed intensivist groups. So you might have like emergency medicine and, you know, pulmonology and surgery all in the same intensivist group. And in that case. They're different specialty codes. Right, well, except for there's an intensivist code that you can use as your second. Right, right, right. Like if they're doing surgery things, we bill them under the surgery code. And if they're doing intensivist care things, we bill them under the intensivist code. So that helps us separate it out. Yeah, that solves the problem. So if they're all performing critical care, but if they're performing critical care on, like, if you have a cardiologist and a, or I'll give you an example. We have in one of our ICUs, if somebody is on like an impella, we have the cardiac surgeons running the impella, the cardiologists running the pressers, and the intensive care people are mostly doing pain management. So, in that case, both cardiology and cardiovascular surgery are doing 9-1s. And since we're actually not doing critical illness, even though the patient is clearly critically ill, the critical care group actually bills other E&M codes. Right, okay. And the pain management, not managing the pain would not bill critical care. Right. Let's see. We have a couple of brain-dead questions here. I knew that was going to come up. Can you bill critical care for the time spent declaring the patient brain-dead, i.e., the clinical exam, the apnea test, intubating the medical exam? No. See, I would say yes, because that's still, the patient is not brain-dead yet. And it's part of the diagnosis. You know, the patient is clearly critically ill, right, or you wouldn't be doing a brain-death exam. I see your point. I see your point. It really hasn't been specified by the payers. It's just that you can't bill critical care for a patient who's been considered brain-dead or has been declared brain-dead. And we had that come up, you know, and this is the second question. Can you bill critical care time initially, and then if the patient passes, take 30 minutes for the discharge? And we actually had that come up recently. Really? Hmm. Yeah. Well, you can't bill for, if the patient was critical, and you billed for that critical portion, probably 9991, unless it's longer and goes on to 292. And now they're brain-dead. Can you bill the discharge? I would say that you're probably going to have a hard time getting paid for that discharge, because the discharge is an E&M service. Right. And it's really clear, you know, I think it's actually even more clear that other E&M services are not paid after critical care. Correct. And so we actually ran that up to CMS, and they're like, no, we wouldn't, or to our MAC, and they said, no, we're not going to pay that. Right, right. They typically will not pay for the discharge once, you know, if critical care is billed on that day. If any E&M service is billed on that day, and you have to discharge the patient officially because they passed away or they, you know, expired, you're not going to bill that discharge. Yeah. When a patient expires, there's a lot of uncompensated time. Right, right. And that's unfortunate. The society should be asking the AMA for the CPT editorial panel for a CPT code for brain-dead, for declaring a patient brain-dead. Okay. You can answer this one, or I can answer it. I know the answer to this one. If critical care APPs are employed by the hospital, whereas the CC physicians are employed by the medical group, how does this change the split-shared rules? Does it apply if we were technically part of two groups? You can answer it if you want. I can, too, but you can't. Yeah. So you have to be in the same group, and that's usually by tax ID. I would also have your legal, whoever asked that question, I don't know if they're still on. I would have the legal department look up Stark Law because you're flirting with the Stark Law violation there, which is that you can't compensate a group. A hospital can't provide compensation, which includes employment of members. There's actually a federal regulation that prohibits that. Yeah. And there's a different federal regulation if the APPs are carried on the, was it Schedule A? Yes. You know, if the hospital is billing for their salaries on Schedule A. Right. And you can't split-share. You know, they're employed by, the APP has to either be employed or contracted by the provider group. Yeah. To split-share. Let me just answer this real quickly. CPT says discharge can include all care on day of discharge. You could bill one or the other. True, but you're almost always, any amount of critical care is going to pay better than the discharge. You know, it's 4.5 RVUs versus, I think it's 2.2 RVUs. Yes, sir. Yes. You almost always want to bill critical care. Right. Conversely, if it's just E&M, then you want to bill discharge as opposed to other E&M. So thank you, everybody. And with that, I think we'll sign off. Thank you, everyone.

Debbie Greiner

billing

documentation updates

critical care services

medical necessity

supporting documentation

split-shared visits

global surgical package

detailed documentation

tele-ICU

pediatric critical care

Billing and Documentation