(Medicare Claims Processing Manual)

F. Emergency Department Physician Requests Another Physician to See the Patient in Emergency Department or Office/Outpatient Setting   If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code.  If the patient is admitted to the hospital by the second physician performing the evaluation, he or she should bill an initial hospital care code and not an emergency department visit code.   30.6.12 - Critical Care Visits and Neonatal Intensive Care (Codes 99291  - 99292)  (Rev. 11288; Issued:0 3- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  30.6.12.1  Definition  (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  For payment under the Medicare Physician Fee Schedule (PFS), Medicare adopts the definition of critical care services in the CPT Codebook, and the CPT listing of bundled services, unless otherwise specified.  This includes t he CPT prefatory language stating that critical care is the direct delivery by a physician(s) or other qualified healthcare professional (QHP) of medical care for a critically ill/injured patient in which there is acute impairment of one or more vital organ systems, such that there is a probability of imminent or life -threatening deterioration of the patients condition.  It involves high complexity decision- making to treat single or multiple vital organ system failure and/or to prevent further life -threatening deterioration of the patients condition.   Bundled services that are included by CPT in critical care services and therefore not separately payable include interpretation of cardiac output measurements, chest X rays, pulse oximetry, blood gases and collection and interpretation of physiologic data (for example, ECGs, blood pressures, hematologic data), gastric intubation, temporary transcutaneous pacing, ventilator management, and vascular access procedures.  As a result, these codes are not separately billable by a practitioner during the time -period when the practitioner is providing critical care for a given patient.  T ime spent performing separately reportable procedures or services should be reported separately and should not be included in the time reported as critical care time.   Because critical care services are delivered by a physician(s) or QHP(s), critical care may be reported by physicians and other practitioners who are qualified by education, training, licensure/regulation (when applicable), facility privileging (when applicable), and the applicable Medicare benefit category to perform critical care services and independently report them, referred to in this manual section as physicians and non- physician practitioners (NPPs).   As specified in CPT prefatory language, critical care may be furnished on multiple days, and is typically furnished in a critical care area, which can include an intensive care unit or emergency care facility.  Critical care requires the full attention of the physician or NPP and therefore, for any given time period spent providing critical care services, the practitioner cannot provide services to any other patient during the same period of time.    30.6.12.2 - Critical Care by a Single Physician or NPP  (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  For payment of critical care by a single physician or NPP, we are adopting CPTs reporting rules.  When a single physician or NPP furnishes 30 - 74 minutes of critical care services to a patient on a given date, the physician or NPP will report CPT code 99291. CPT code 99291 will be used only once per date even if the time spent by the practitioner is not continuous on that date.  Thereafter, the physician or NPP will report CPT code 99292 for additional 30 -minute time increments provided to the same patient.    CPT codes 99291 and 99292 will be used to report the total duration of time spent by the physician or NPP providing critical care services to a critically ill or critically injured patient, even if the time spent by the practitioner on that date is not continuous. Non- continuous time for medically necessary critical care services may be aggregated.    Regarding critical care services crossing midnight, CPT guidance defines how a service is to be billed when the service extends across calendar dates. For continuous services that extend beyond midnight, the physician or NPP will report the total units of time provided continuously. Any disruption in the service, however, creates a new initial service. We are adopting this rule for critical care being furnished by a single physician or NPP when the critical care crosses midnight.   30.6.12.3 - Critical Care Visits Furnished Concurrently by Different Specialties (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  Concurrent care is when more than one physician renders services that are more extensive than consultative services during a period of time. The reasonable and necessary services of each physician furnishing concurrent care is covered when each plays an ac tive role in the patients treatment. In  the context of critical care services, a critically ill patient may have more than one medical condition requiring diverse , specialized medical services and requiring more than one practitioner , each having a differ ent specialt y, play ing an active role in the patients treatment.    Medicare policy allows critical care visits furnished as concurrent care (or concurrently) to the same patient on the same date by more than one practitioner in more than one specialty (for example, an internist and a surgeon, allergist and a cardiologist, neurosurgeon and NPP) , regardless of group affiliation, if the  service meet s the definition of critical care and is not duplicative of other services.  Additionally, these critical care visits need to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to im prove the functioning of a malformed body member.   30.6.12.4 - Critical Care Furnished Concurrently by Practitioners in the Same Specialty and Same Group (Follow-Up Care)  (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  Physician(s) or NPP (s) in the same specialty and in the same group may provide concurrent follow -up care, such as  a critical care visit subsequent to another practitioners critical care visit.  This  may be  as part of continuous staff coverage or follow -up care to critical care services furnished earlier in the day on the same calendar date.   In the situation where a practitioner furnishes the initial critical care service in its entirety and reports CPT code 99291, any additional practitioner(s) in the same specialty and the same group furnishing care concurrently to the same patient on the sa me date report their time using the code for subsequent time intervals (CPT code 99292). CPT code 99291 will not be reported more than once for the same patient on the same date by these practitioners. This policy recognizes that multiple practitioners in the same specialty and the same group can maintain continuity of care by providing follow -up care for the same patient on a single date.   When one practitioner begins furnishing the initial critical care service, but does not meet the time required to report CPT code 99291, another practitioner in the same specialty and group can continue to deliver critical care to the same patient on the s ame date. The total time spent by the practitioners is aggregated to meet the time requirement to bill CPT code 99291. Once the cumulative required critical care service time is met to report CPT code 99291, CPT code 99292 can only be reported by a practitioner in the same specialty and group when an additional 30 minutes of critical care services have been furnished to the same patient on the same date (74 minutes + 30 minutes = 104 total minutes).  The aggregated time spent on critical care visits must be medically necessary and each visit must meet the definition of critical care in order to add the times for purposes of meeting the time requirement to bill CPT code 99291.    For purposes of payment under the Physician Fee Schedule, Medicare classifies NPPs in a specialty that is not the same as a physician with whom the NPP is working, so the policies above would not apply to the situation where an NPP provides the follow -up care to a physician, or vice versa.  Instead, see the section below regarding split (or shared) critical care services.   30.6.12.5 - Split (or Shared) Critical Care Visits  (Rev.  11828; Issued: 02- 02-23; Effective: 01 -01-23; Implementation: 03 -03-23)  Critical care visits may be furnished as split (or shared) visits, defined in section 30.6.18. The rules described in section 30.6.18 for other types of split (or shared) visits apply (except for the listing of qualifying activities for determining the sub stantive portion, discussed below), and service time is counted for CPT code 99292 in the same way as for prolonged E/M services .  Specifically, the billing practitioner bills the initial service (CPT 99291) and any add- on codes(s) for additional time (CPT  99292). Also, the substantive portion for critical care services is defined as more than half of the total time spent by the physician and NPP beginning January 1, 2022.  In the context of critical care, split (or shared) visits occur when the total critical care service time furnished by a physician and NPP in the same group on a given calendar date to a patient is summed, and the practitioner who furnishes the substantive portion of the cumulative critical care time reports the critical care service(s).   As stated earlier, when critical care services are furnished as a split (or shared) visit, the substantive portion is defined as more than half the cumulative total time in qualifying activities that are included in CPT codes 99291 and 99292.  Since, unlike other types of E/M visits, critical care services can include additional activities that are bundled into the critical care visits code(s), there is a unique listing of qualifying activities for split (or shared) critical care.  These qualifying activiti es are described in the prefatory language for critical care services in the CPT Codebook.  To bill split (or shared) critical care services, the billing practitioner first reports CPT code 99291 and, if 104 or more cumulative total minutes are spent providing critical care, the billing practitioner reports one or more units of CPT code 99292. Modifier - FS (split or shared E/M visit) must be appended to the critical care CPT code(s) on the claim.   The same documentation rules apply for split (or shared) critical care visits as for other types of split (or shared) E/M visits. Consistent with all split (or shared) visits, when  two or more practitioners spend time jointly meeting with or discussing the patient as part of a critical care service, the time can be counted only once for purposes of reporting the split (or shared) critical care visit.   30.6.12.6 - Critical Care and Other Same -Day Evaluation and Management (E/M) Visits  (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  Our general policy, as described in section 30.6.5, states that physicians in the same group who are in the same specialty must bill and be paid for services under the PFS as though they were a single physician. If more than one E/M visit is provided on the same date to the same patient by the same physician, or by more  than one physician in the same specialty in the same group, only one E/M service may be reported, unless the E/M services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. T his general policy is intended to ensure that multiple E/M visits for a patient on a single day are medically necessary and not duplicative.    However, in situations where a patient receives another E/M visit on the same calendar date as critical care services, both may be billed (regardless of practitioner specialty or group affiliation) as  long as the medical record documentation supports: 1) that the other E/M visit was provided prior to the critical care services at a time when the patient did not require critical care, 2) that the services were medically necessary, and 3) that the services were separate and distinct, with no duplicative eleme nts from the critical care services provided later in the day. Practitioners must use modifier - 25 (same -day significant, separately identifiable evaluation and management service) on the claim when reporting these critical care services.    30.6.12.7 - Critical Care Visits and Global Surgery    (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)