Critical Care MeAHIMA · 2016-03-10 · Clinical examples (CMS) which may not warrant critical care services Daily management of patient on chronic ventilator therapy Management of

Dianne Rodrigue, PA, MHP, CCDS, CPC

Critical Care Services

MEHIMA Spring MeetingMarch 17, 2016

Disclaimer

This presentation is for general education purposes only. The information contained in these materials and presented during the lecture or in response to your questions is not intended to be, and is not, legal advice. The laws and regulations at issue in this lecture may be open to interpretation.

This information may not be copied, reproduced, dismantled, quoted, or presented without the expressed written approval of BNN. No part of this presentation may be reproduced, stored in a retrieval system or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording, or taping) without the expressed written permission from BNN.

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Objectives

Review definition of critical care services

CMS and CPT®

Identify the key documentation and coding requirements

Medical Necessity and Time

Clarify guidelines for reporting critical care services as a teaching physician and for Non-Physician Providers (NPPs)

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Critical Care Definition

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Definition Direct delivery by physician(s) or other qualified health

care professional of medical care for a critically ill or injured patient.

Critical illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition, i.e. urgent care.

Critical intervention involves decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.

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DefinitionExamples of vital organ system

failure include, but are not limited to: Central Nervous System (CNS) failure

Circulatory failure

Shock

Renal, hepatic, metabolic and/or respiratory failure

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DefinitionCritical care is not predicated on place of

service, i.e. consider patient’s condition and intensity of service, not patient location.

Treatment and management of the patient’s condition, while not necessarily emergent, shall be required based on the threat of imminent deterioration.

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Clinical examples (CMS) that maywarrant critical care services

67 year old female 3 days status post mitral valve repair, develops petechiae, hypotension and hypoxia requiring respiratory and circulatory support.

70 year old admitted for RLL pneumococcal pneumonia with history of COPD, becomes hypoxic and hypotensive 2 days after admission requiring respiratory and circulatory support.

81 year old male admitted to the intensive care unit following AAA resection. Two days after surgery he requires fluids and pressors to maintain adequate perfusion and arterial pressures. He remains ventilator dependent.

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Clinical examples (CMS) which may not warrant critical care services

Daily management of patient on chronic ventilator therapy

Management of dialysis or care related to dialysis for ESRD

Patients admitted to a critical care unit for close nursing observation and/or frequent monitoring of vital signs (e.g., drug toxicity or overdose)

Patients admitted to a critical care unit because hospital policy requires certain treatments to be administered in the critical care unit (e.g. insulin or other drug infusions) 9

Critical Care Services and Medical Necessity

Social Security Act §1862(a)(1)(A)

All billed services must be based only on activities that are reasonable and necessary for the diagnosis or treatment of illness or injury.

CMS Pub 100-4, Chapter 12, Subsection 30.6.1Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT® code.

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Supporting medical necessity

1. Is the patient critically ill, i.e. life threatening scenario?

2. Were interventions performed using “high complexity medical decision making to assess, manipulate, and support vital systems to treat single or multiple vital organ system failure and/or prevent further life threatening deterioration of the patient’s condition”?

3. Time requirements met? The critical and unstable nature of the patient’s condition should be accurately

documented to support the medical necessity of the extended 1 to1 services.

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Critical Care Services and Time

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Total Duration of Critical Care

Appropriate CPT® Codes

Less than 30 minutes 99232 or 99233 or other appropriate E/M code

30 – 74 minutes 99291 X 1

75 –104 minutes 99291 X 1 and 99292 X 1

105 – 134 minutes 99291 X 1 and 99292 X 2

135 – 164 minutes 99291 X 1 and 99292 X 3

165 – 194 minutes 99291 X 1 and 99292 X 4

194 minutes or longer 99291-99292 as appropriate (per the above illustrations

Critical Care Time

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Critical Care Services and Time Minimum of 30 minutes to report

May be continuous or aggregate, i.e. total duration

of time on date of service

Report range of time (9:00-9:45) or total time (45 min)

Initial critical care time (99291) must be met by single provider. Physicians with same specialty and from same group practice can not

report 99291 for same patient on same calendar date.

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Subsequent critical care visits (99292) may represent aggregate time by single physician or physicians within same group practice with same specialty designation, providing medical necessity requirements met.

Physicians assigned to critical care unit (hospitalist/intensivist) may not report critical care based on a per shift basis.

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Coding critical care services that span the calendar date

Example: CC begins at 11:30 pm and continues until 12:15 am the next calendar day.

Report 99291 for Day 1

Example: CC begins at 11:30 and continues until 12:15am the next calendar day. CC reinitiated at 2:00 am until 3:00 am.

Report 99291 for Day 1 and 99291 for Day 2

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Critical Care Service and Time

Caution:Submission of claims for greater than 12 hours

of critical care by one provider for one or more patients on same calendar date.

Submission of claims from several providers for multiple units of critical care for single patient.

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Critical Services and Full Attention

Activities include evaluating, managing, and providing care to critically ill or injured patient.

Full attention: cannot provide services to any other patient.

Time must be spent at the patient’s bedside or elsewhere on the unit but must be immediately available to the patient.

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Critical Care Services and reportable activities All work related to patient’s care that occurs on the

floor/unit direct bedside time

time spent reviewing test results and/or reviewing old records,

discussing case with staff,

documenting in the medical record, and

time spent with family members or other decision makers when patient is unable to make decision as long as work is directly related to patient’s care and management.

Time spent off the unit/floor can not be counted (even if related to patient’s care). 19

Critical Care Services and reportable activities

Time speaking with family can be reported as critical care if: Patient is unable to participate in giving history and/or

making treatment decisions Discussion is necessary for determining treatment

decisions and the nature of those treatment decisions *Routine daily updates to family do not specifically count towards

critical care time

Necessity to have the discussion Ex. “Due to rapid deterioration, I needed to immediately

discuss treatment options with the family”

Discussions occur while immediately available to patient

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Critical Care Services and Bundled Procedures

Do not report separately on day provider bills for Critical Care Services (time spent performing these services may be counted towards critical care)

Interpretation of cardiac output measurements (93561, 93562)

Chest x-rays, professional component (71010, 71015, 71020)

Blood gases, and information data stored in computers (e.g., EKGs, hematologic data-99090)

Gastric intubation (43572, 91105)

Pulse oximetry (94760, 94761, 94762)

Transcutaneous pacing (92953)

Ventilator management (94002-94004, 94660, 94662)

Peripheral vascular access procedures (36000, 36410, 36415, 36591, 36600)

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Critical Care Services and Unbundled Procedures

Time spent performing these procedures is not considered when determining critical care time.

Examples of common procedures for critically ill or injured patient which may be separately billed:

CPR (92950)

Endotracheal intubation (31500)

Central line placement (36556)

Arterial catheterization (36620)

Tube thoracostomy (32551)

Temporary transvenous pacemaker (33210, 33211)22

Critical Care Services Documentation

Documentation must support:

Patient’s condition meets the definition of a critical illness or injury, i.e. statement covering the nature of the critical illness or injury.

Total critical care time-minimum of 30 minutes. (Key component)

Description of all physician’s interval assessments of the patient’s condition, any acute “impairments of organ systems”, description of significant lab, imaging, EKG findings, timing and rationale of interventions, and patient response to treatment.

Separately reportable procedures not included in the aggregation of critical care time should be clearly delineated.

Statement indicating that time spent performing separately reportable procedures was not included in total critical care time.

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Critical Care Services Documentation Not subject to same requirements that apply to other E/M

services (History, Physical Exam, Medical Decision Making). Admission note and/or progress note and documentation of

critical care episode should stand apart and be readily identifiable within the medical record. Longer periods of critical care (e.g. >104 minutes) should

be supported with interval notes justifying the critical and unstable nature of the patient requiring extended time spent in direct patient care.

** Under review, the severity of the illness itself, the care provided, and the time claimed may all be considered.

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Troublesome Critical Care documentation:

“No acute events overnight”

“NAD”

“Resting comfortably”

“VSS”

Critical illness/injury ruled out

Reasonableness of time statement

“Medical record documentation of critical care services should demonstrate the patient’s condition warranted the type and amount of services provided.”

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Critical Care Services Documentation CC: shot into bullet proof vest

HISTORY

Comprehensive History obtained from patient & documented

PE

Primary Survey A-Patent B-Spont C-Intact

Secondary Survey normal VS

PE

WNL (7 Body Areas/Organ Systems)

Chest exam-CTAB, tender to palpation anterior chest

Ext-Decreased sensation RLE, Pain with R hip flexion

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Data-CXR, Chest CT, Head CT all normal

“Case discussed with attending”

IMPRESSION (attending documentation)

GSW to Kevlar vest

“No apparent injury other than anterior chest wall contusion. May discharge home.”

Critical care time: 35 minutes

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ICU Day #9

Patient examined and discussed with ICU team.

Critical care diagnoses

Subacute delirium

Bilateral pneumothorax

Acute blood loss anemia

Hypoxia

Severe protein malnutrition

No hyperglycemia

Plan

Pain regimen addressed; OT/PT

Right chest tube remains

On Supplemental O2

Started on dysphagia diet

Family updated.

Will transfer to ward.

Critical care time: 90 minutes28

Critical Care Services and Multiple Physicians/Providers

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Multiple Providers of Critical Care

Concurrent care as defined by Medicare:When more than one physician (hospitalist, intensivist, surgeon, etc.) renders services more extensive than evaluating and providing an opinion on an aspect of the patient’s care during a period of time.

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CMS-Concurrent critical care services provided by each physician must be medically necessary and not provided during the same instance of time.

CPT®-Only one physician/provider may report services for a given hour of critical care, even if more than one physician/provider has rendered care to the patient.

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May be paid if: Meets critical care criteria

Medically necessary

Not duplicative

Generally of a different specialty

Example Cardiologist vs. Pulmonologist

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Under review, the following will be considered to support concurrent care:

Patient’s condition and if it warrants services of more than one physician on more than an advisory basis, considering the patient’s diagnosis and the physician’s specialties/subspecialties addressing different aspects of care.

Services can not duplicate one another; each physician must be managing one or more critical illness(es) or injury(ies).

Different diagnosis codes help distinguish that care is not overlapping.

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Critical Care in the ED Patient arrives to ED with crushing chest pain and full

cardiac work up performed

ED provider provides 35 minutes of critical care and reports 99291

Cardiologist called to evaluate and takes over care of patient, provides critical care services, and admits the patient to the CCU

Cardiologist may also report 99291 34

Critical Care and other Evaluation and Management on the Same Day Physician saw patient in the morning in the hospital and

reported subsequent hospital care.

Later in the day, patient becomes acutely ill and critical care services are performed by NPP from same group.

Physician reports appropriate E/M under NPI

Critical care services reported under NPP’s NPI with Modifier 25

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Critical Care-Two Physicians of Same Specialty

Dr. A-Cardiologist performs 40 minutes critical care in the morning

Dr. B-Cardiologist from same group performs 30 minutes of critical care in the evening

Report 99291 under either physician’s NPI, but not both as combined time does not exceed threshold for billing subsequent critical care (74 minutes)

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Critical Care-Two Physicians of Same Specialty

Dr. A a pulmonologist performs 45 minutes of critical care

Dr. B a cardiologist same practice performs 40 minutes of critical care

Dr. A bills a 99291

Dr. B could bill a 99291 as long as the services are not duplicative

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NPPs and Critical Care Services

A split/shared E/M service performed by a qualified NPP and physician of the same group practice (or employed by the same employer) cannot be reported as a critical care service.

May not be reported as combined service or sum of individual times.

Critical care services are reflective of care and management of individual physician or qualified NPP for the specified reportable period of time. 38

NPPs and Critical Care Services

Should be reported under the National Provider Identifier (NPI) of the physician or qualified NPP respectively, when documentation supports code and time requirements.

Specific state, hospital, or insurance restrictions may apply to billing of critical care services by NPP.

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Critical Care Services and Global Period

Preoperative critical care may be paid in addition to global fee if… Patient is critically ill and requires full attention of physician; and Service is unrelated to specific anatomic injury or general surgical procedure performed Modifier 25 with 99291and/or 99292

Postoperative critical care may be paid in addition to global fee if… Documentation supports that critical care was unrelated to specific anatomic surgery performed Modifier 24 with 99291 and/or 99292

Time spent performing the pre, intra and/or post procedure work shall be excluded from the time spent providing critical care. 40

Teaching Physicians

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Critical Care Services: Teaching Physician

Teaching physician must be present for the entire period of time for which the claim is submitted.

Time spent teaching may not be counted towards critical care time.

Teaching physician cannot bill for time spent by the resident providing critical care services in their absence.

Only time that the teaching physician spends alone with the patient, or that he/she and the resident spend together with the patient, can be counted toward critical care time. 42

Critical Care Services: Teaching Physician Documentation

Teaching physician’s documentation may tie into the resident's documentation-may refer to the resident’s documentation for specific patient history, physical findings and medical assessment.

The teaching physician’s “stand alone”documentation is what determines whether a critical care service(s) can be billed. 43

Critical Care Services: Teaching Physician Documentation

CMS requirements:

(1) the time the teaching physician spent providing critical care,

(2) that the patient was critically ill during the time the teaching physician saw the patient,

(3) what made the patient critically ill, and

(4) the nature of the treatment and management provided by the teaching physician.

Medical review criteria are the same for the teaching physician as for all physicians re: critical care. 44

Documentation example 99291: Patient seen and examined with Dr. (Resident). Reviewed and

agree with his/her note and the plan of care we developed together. One hour of critical care time personally performed due to patient’s hemodynamic instability. Patient was resuscitated with 2 units of packed red blood cells, vasopressor drugs and is currently stable.

Teaching physician personally present

Acute impairment of vital organ system

Treatment(s) initiated

Response to treatment

Total critical care time45

Coding example50 year old female, MVA, brought to ED with tibia fracture and splenic bleed-surgeon consulted:

Initially hypotensive but responded to fluid resuscitation

Central venous catheter placed due to poor IV access

Trauma Surgeon evaluated patient-initial and secondary survey, FAST, CT scan abdomen & pelvis, blood, urine, EKG, lower extremity xray

• Significant for small tear and blood around spleen, low HCT & tibia fracture

Communicated with orthopaedic surgeon, PCP, family while in ED

• = 90 minutes of direct attendance in ED, exclusive of catheter insertion

• CPT® codes include-99291, 99292(Critical care-ED), 36556

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Coding example

Patient admitted to SICU, Trauma Service with orders for blood transfusion & continued monitoring overnight in ICU.

HD 2-no events overnight; remains stable and orthopaedic surgeon plans for ORIF tibia later in the day

• CPT® code-99232, Subsequent hospital care

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References: Medicare Claims Processing Manual, Chapter 12 (Physicians/Nonphysician

Practitioners) Sections 30.6.12 & 40-Accessed February 2016.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

CMS Transmittal 1548 & MLN Matters: MM5993-Critical Care Visits (Codes 99291-99292)

CMS Global Surgery Billing Guide 2015

Current Procedural Terminology 2016, Professional Edition

CPT® Assistant, August 2014, July 200648

Contact the presenter:

Dianne Rodrigue, PA, MHP, CCDS, CPC

[email protected]

207-791-7517

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Critical Care MeAHIMA · 2016-03-10 · Clinical examples (CMS) which may not warrant critical care services Daily management of patient on chronic ventilator therapy Management of

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