(Medicare Claims Processing Manual)

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 diagnosi s or treatment of illness or injury or to improve 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 practit ioner 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 comb ined visits and submit the appropriate code for that level. This 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)  Critical care visits are sometimes needed during the global period of a procedure, whether pre -operatively, on the same day, or during the post -operative period. In some cases, preoperative and postoperative critical care visits are included in procedure codes that have a global surgical period.  In those cases where a critical care visit is unrelated to the procedure with a global surgical period, critical care visits may be paid separately in addition to the procedure. Preoperative and/or postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the full attention of the physician, and the critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure perf ormed (for example, trauma, burn cases). When the critical care service is unrelated to the procedure, append the modifier -FT ((unrelated evaluation and management (E/M) visit on the same day as another E/M visit or during a global procedure (preoperative, postoperative period, or on the same day as the procedure, as applicable). (Report when an E/M visit is furnished within the global period but is unrelated, or when one or more additional E/M visits furnished on the same day are unrelated.)) to the critical care CPT code(s).    If care is fully transferred from the surgeon to an intensivist (and the critical care is unrelated), modifiers - 54 (surgical care only) and - 55 (postoperative management only) must also be reported to indicate the transfer of care. The surgeon will report  modifier - 54.  The intensivist accepting the transfer of care will report both modifier - 55 and modifier - FT.  As usual, medical record documentation must support the claims.    30.6.12.8 - Medical Record Documentation  (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  Critical care is a time -based service, and therefore, practitioners must document in the medical record the total time (not necessarily start and stop times) that critical care services are furnished by each reporting practitioner.  Documentation needs to indicate that the services furnished to the patient, including any concurrent care by the practitioners, are medically reasonable and necessary for the diagnosis and/or treatment of illness and/or injury or to improve the functioning of a malformed body me mber.   To support coverage and payment determinations regarding concurrent care, services must be  sufficiently documented to allow a medical reviewer to determine the role each practitioner played in the patients care (that is, the condition or conditions for which the practitioner treated the patient).   When critical care services are reported the same date as another E/M visit, the medical record documentation must support: 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 elements from the critical care services provided later on that date.