Advocacy Info: Critical Care
"Policy Issues Related to Critical Care"
The following memo entitled “Policy Issues Related to Critical Care” was issued on February 10, 1995, by Elizabeth Cusick, the Director of Physicians and Ambulatory Care Policies, BPD, Health Care Financing Administration, to all Associate Regional Administrators for Medicare.
We have been asked to clarify a number of issues related to the interpretation, reporting, and payment of Current Procedural Terminology (CPT) critical care codes 99291 and 99292. It has been alleged that some carriers are limiting the use of the codes to the care of patients in shock or cardiac arrest; that limits have been placed on the number of hours of critical care per day or days per hospital stay; and that payment for critical care on the same date as a procedure, such as endotracheal intubation is being denied even if modifier –25 is used with the critical care codes.
To reiterate previous directives and to further clarify our policies, please note the following:
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Use of the critical care codes 99291 and 99292 in cases which are not medical emergencies.
The CPT definition of critical care services states that:
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Critical care includes the care of critically ill or injured patients in a variety of medical emergencies that require the constant attendance of the physician (eg, cardiac arrest, shock, bleeding, respiratory failure, postoperative complications).
This statement appears to have been interpreted by some carriers to mean there must be a medical emergency for critical care to be billed. Such an interpretation is too narrow and restricts the use of the critical care codes inappropriately.
Based on the advice of a workgroup of our carrier medical directors, and representatives of several specialty societies, as well as a review of the relative value units assigned to these codes, we have determined that critical care also includes the care of patients who might not be in a “medical emergency” but who nonetheless require constant physician attention because they are unstable and critically ill or unstable and critically injured.
The care of such patients involves decision making of high complexity to assess, manipulate, and support circulatory, respiratory, central nervous, metabolic, or other vital system functions to prevent or treat single or multiple vital organ system failure. It often also requires extensive interpretation of multiple databases and the application of advance technology to manage the patient.
This expanded definition does not mean that the care of a patient who happens to be in a critical care, intensive care, or other specialized care unit should be reported with the critical care codes. In such a unit, the care of a patient who is not unstable and critically ill or unstable and critically injured is reported using the appropriate subsequent hospital care code (99231-99233) or inpatient consultation code (99251-99263).
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“Constant attendance” as a prerequisite for the use of the critical care codes.
The CPT codes for reporting critical care services are:
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99291—Critical care, evaluation and management or the critically ill or critically injured patient, requiring the constant attendance of the physician; first hour
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99292—Each additional 30 minutes
The notes which precede the code state “The critical care codes are used to report the total duration of time spent by a physician providing constant attention to a critically ill or critically injured patient…” The terms “constant attendance” and “constant attention” appear to have been interpreted by some carriers to mean that the physician may only report the time spent at the immediate bedside of the patient. Such an interpretation is too narrow and restricts the use of the critical care codes inappropriately.
The time that can be reported as critical care is not limited to the time spent at the immediate bedside of the patient. The intent of the terms “constant attendance” and “constant attention” is to permit the physician to report the time spent engaged in work directly related to the individual patient's care whether that time was spent at the immediate bedside or elsewhere on the floor or unit. For example, time spent reviewing laboratory test results, discussing the critically ill patient's care with other medical staff in the unit or at the nursing station on the floor would be reported as critical care, even if it does not occur at the bedside.
Time spent in activities that occur outside of the unit or off the floor (eg, telephone calls, whether taken at home, in the office or elsewhere in the hospital) may not be reported as critical care since the physician is not immediately available to the patient. Time spent in activities that do not directly contribute to the treatment of the patient may not be reported as critical care, even if they are performed in the critical care unit (eg, telephone calls to discuss other patients).
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Hours and days of critical care that may be billed.
It has been alleged that some carriers are arbitrarily deny critical care after a fixed number of hours of critical care or a fixed number of days on which critical care was billed. If true, such denials would be contrary to previously established national policy and should be discontinued.
The following national policies on the amount of critical care services that can be billed were first issued on May 29, 1992, in a memorandum from the Director, Office of Payment Policy, to all Associate Regional Administrators for Medicare. These policies remain in effect.
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There are no absolute limits on the amount of critical care services hat can be billed per day or per hospital stay.
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A physician must be prepared to demonstrate that the service billed meets their definition of critical care
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The carrier may request documentation for cases in which it is implausible that the amount of critical care billed was provided (eg, more that a total of 12 hours of critical care billed by a physician for one or more patients on the same day).
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Only one physician may bill for a given hour of critical care even if more than one physician is providing care to a critically ill patient.
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Use of modifier –25 to permit payment of critical care on the day of a procedure with a global fee period.
Critical care cannot be paid on the day the physician also bills a procedure code with a global surgical period unless the critical care is billed with the CPT modifier –25 to indicate that the critical care is a significant, separately identifiable evaluation and management service that is above and beyond the usual pre- and post-operative care associated with the procedure that is performed. It appears that some carriers do not permit payment for the critical care on the same day as a procedure with a global surgical period even if it is billed with the CPT modifier –25.
This issue was addressed in regard to evaluation and management services in general in our memorandum to all Associate Regional Administrators of August 27, 1993. Please remind carriers that critical care codes are evaluation and management services and that the discussion of payment for services billed with the CPT modifier –25 also applies to critical care codes 99291 and 99292.
We believe that if denials for critical care are occurring, they may relate to a misunderstanding of what services are included or bundled into critical care. Prior to 1993, the CPT definition of critical care bundled a number of fairly significant procedures into the critical care codes, including endotracheal intubation and placement of catheters. At that time, it would have been consistent with the CPT definition of carriers to deny payment for these procedures when that were billed on the same date as the critical care codes. However, beginning in 1993, the CPT definition of critical care in CPT was revised and we assigned relative value units to the critical care codes to be consistent with the revised definition. (See page 27 of CPT 1995 for a list of services that are included in reporting critical care.)
Services such as endotracheal intubation (CPT code 31500) and the insertion and placement of a flow directed catheter, eg, Swan-Ganz, (CPT 93503) are no longer bundled into the critical care codes. Therefore, separate payment may be made for critical care in addition to these services, if the critical care was a significant, separately identifiable service and it was reported with modifier –25. The time spent performing these other unbundled services (eg, endotracheal intubation) is excluded from the determination of the time spent providing critical care.
Please note this policy applies to any procedure with a 0, 10 or 90 day global period including cardiopulmonary resuscitation (CPT code 92950). CPR has a global period of 0 days and is not bundled into the critical care codes. Therefore, critical care may be billed in addition to CPR if critical care was a significant, separately identifiable service and it was reported with a modifier –25. The time spent performing CPR is excluded from the determination of the time spent providing critical care.
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