- Critical care provided as a stand alone service is based on the seriousness of the patient, the types of interventions, and time
- Critical care provided by a surgeon to a patient in a global period for a minor or major procedure, must also follow the rules for the global surgical payment, with the added complication of following global surgical rules
Critical care services provided by a surgeon before, on the day of, and after a major surgical procedure are complicated by the payment rules for the global surgical package. Payment for the global surgical package includes all of the typical services provided by a surgeon, or by the surgeon’s same specialty partners in their group.
So, in addition to mastering the rules for critical care, there is an added filter to consider. Is the critical care part of the global payment? When can it be billed in addition to the global payment for the surgery?
The CPT® and the CMS rules are slightly different. For CPT®, “typical” post-op is part of the global package.
From the Medicare Claims Processing Manual: Medicare Critical Care Rules – Critical Care Services Provided During Preoperative Portion and Postoperative Portion of Global Period of Procedure with 90 Day Global Period in Trauma and Burn Cases
Preoperative critical care and/or postoperative care may be paid in addition to a global fee if the patient is critically ill and requires the full attention of the physician, and the critical care is unrelated to the specific anatomic injury or general surgical procedure performed. Such patients may meet the definition of being critically ill and criteria for conditions where there is a high probability of imminent or life threatening deterioration in the patient’s condition.
For preoperative care modifier 25 (significant, separately identifiable evaluation and management services by the same physician on the day of the procedure) must be used with the HCPCS code.
For postoperative care modifier 24 (unrelated evaluation and management service by the same physician during a postoperative period) must be used with the HCPCS code.
In addition, for each preoperative and postoperative care the diagnosis must clearly indicate that the critical care was unrelated to the surgery.
Medicare Claims Processing Manual, 100-04, Chapter 12, Sections 30.6.12 L
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