CPT^® and CMS rules for critical care | What’s the difference?

There are some significant differences in critical care rules as described in CPT^® and in the Medicare Claims Processing Manual.¹ 

This makes it difficult for physicians and coders alike.  Although I usually don’t suggest using Medicare rules for all payers, I do suggest it for critical care in adult medicine. It decreases complexity, and means clinicians don’t have to remember two sets of rules. Critical care is an E/M service with high reimbursement, and doing it right is important.

Use of emergency department codes and critical care codes on the same day

CMS specifically prohibits billing an ED visit and critical care on the same day, by the same physician.  Keep in mind the rule about billing for services by physicians in groups: bill for physicians of the same specialty in the same group as if they were one physician.

That means, one ED doctor can’t bill for 99285 and a second ED doctor in the same group bill 99291.  And, no physician can bill both an ED visit and critical care on the same calendar day.

From the manual:

“Hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician to the same patient.”

CPT^® does not make this distinction.  It simply says:

“Critical care and other E/M services may be provided to the same patient on the same date by the same individual.”

Neither CPT^® nor Medicare prohibit billing other E/M services on the day of critical care, if they were separate and distinct.  That means, the services were provided before or after the critical care service, at a time when the patient was not critically ill. And, an ED physician can bill an ED visit and a trauma surgeon can bill critical care on the same day. The prohibition is within specialty designation.

Shared billing between a physician and non-physician practitioner

CPT^® doesn’t describe sharing critical care services between a physician and NPP in the same group.

CMS specifically prohibits adding together the time spent by the physician and the time spent by the NPP in determining critical care time.  The group may bill either for the NPP or for the physician, but may not combine their services on the bill.

From the manual (citation in footnotes)

“Unlike other E/M services where a split/shared service is allowed the critical care service reported shall reflect the evaluation, treatment and management of a patient by an individual physician or qualified non-physician practitioner and shall not be representative of a combined service between a physician and a qualified NPP.”

More than one physician providing critical care at the same time

CMS does allow for more than one physician of different specialties to provide and bill for critical care during a calendar date.  The care must not be duplicative.  And, CMS restricts the time period.

From the CMS manual:

“Only one physician may bill for critical care services during any one single period of time even if more than one physician is providing care to a critically ill patient.”

Finally, CMS is very specific that one physician or NPP must meet the entire time requirement of 99291. This is important if additional critical care time is provided by another same specialty/same group physician later in the day.

“The initial critical care time, billed as CPT^® code 99291, must be met by a single physician or qualified NPP. This may be performed in a single period of time or be cumulative by the same physician on the same calendar date.”

Transferring a critically ill newborn or child

Remember that a physician who is caring for a critically ill child and arranging for transfer to another facility also uses codes 99291—99292 to report these services.

CPT^® states:

“Also report 99291—99292 for neonatal or pediatric critical care services provided by the individual providing critical care at one facility but transferring the patient to another facility.”

What else should I know about coding for critical care?

This article is not comprehensive, but rather discusses differences and sticking points in critical care. There are other articles on CodingIntel that describe the rules of coding for critical care.

Although I’ve been reading about, writing about and coding critical care for a long time, it’s complicated.  I find it very helpful to re-read the editorial comments in CPT^® and the CMS manual pages periodically.  If you’re coding for critical care, I suggest you do too.

CMS	CPT®
The first hour (74 minutes) must be provided by one physician, before a second physician may use the add-on code 99292	CPT® is silent on this
Physicians and non-physician practitioners may not share critical care time	CPT® is silent on this
Two physicians may not bill for the same instance of time (8-9 am, for example)	CPT® is silent on this
One physician may not bill both ED codes 99281–99285 and critical care for the same patient on the same day	CPT® is silent on this

Two physicians billing for same time period

Question:

Where does it say in CPT^® that two physicians can’t bill for the same period of time when performing critical care?

Answer:

It doesn’t. This is a Medicare rule.

There are two significant differences in critical care coding rules between CPT^® and CMS. (Wouldn’t our lives be easier if they were the same?)

The first is that CMS says one physician (and physicians in a group of the same specialty are considered one physician) cannot bill for ED visits and critical care in the same day.  That isn’t a CPT^® rule.  Here’s the citation for that.  

“When critical care services are required upon the patient’s presentation to the hospital emergency department, only critical care codes 99291 – 99292 may be reported. An emergency department visit code may not also be reported.”[2]

The second is this issue about billing for the same time period. The manual, quoted below, says that during any one single period of time, only one physician can bill for critical care, even if more than one is providing care.

 “Only one physician may bill for critical care services during any one single period of time even if more than one physician is providing care to a critically ill patient.”[3]  

And of course, the care cannot be duplicative.

CodingIntel members can download the Critical Care Coding Guide for more detail.

Citations:

¹ CPT^® 2021 Professional Edition pages 31-33 and Medicare Claims Processing Manual, Chapter 12, Section 30.6.12

² CMS Medicare Claims Processing Manual, 100-04, Chapter 12, Section 30.6.12 H

³ CMS Medicare Claims Processing Manual, 100-04, Chapter 12, Section 30.6.12 F

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