Documentation and billing for the services provided to a critically ill patient can be complex and challenging. Critical care, evaluation and management, and procedures can be billed to get reimbursed for the services provided. An understanding of the documentation requirements and contextual application is fundamentally important to optimize revenue capture. Billing correctly for situations such as advance care planning and extracorporeal membrane oxygenation requires special considerations and supportive documentation. A compliance program that oversees accurate documentation and billing not only provides for clinician education but also minimizes risk to the organization.
Key points
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Documentation and billing for critical care is complex. Understanding of the key requirements is needed for billing correctly.
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Procedures and special circumstances (eg, advanced care planning) can be billed for separately as long as supportive documentation is available.
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An institutional governance process within critical care organizations to ensure education and audit is essential to support optimal documentation and billing for critically ill patients.
Abbreviations
| ACP | advanced care planning |
| AMA | American Medical Association |
| CCO | Critical Care Organization |
| CMS | Centers for Medicare and Medicaid Services |
| CPT | current procedural terminology |
| DRG | diagnosis-related group |
| E/M | evaluation and management |
| ECMO | extracorporeal membrane oxygenation |
| HHS | Health and Human Services |
| ICD | International Classification of Diseases |
| LIPs | licensed independent provider |
| MDM | medical decision-making |
| NPI | National Provider Identifier |
| NPPs | nonphysician practitioners |
| NPs | nurse practitioners |
| OIG | Office of Inspector General |
| PAs | physician assistants |
| POCUS | point-of-care ultrasound |
| QHP | qualified health providers |
Introduction
The process of management of a critically ill patient is very resource intensive. Expert clinicians, state-of-art technology, expensive therapeutics, and a complex environment are needed to deliver care to the critically ill patients. Considering these costs, optimization of revenue flow for sustenance of high level of care delivery is essential. In most of the facilities, this revenue comes from billing the patient or their insurance for clinician management and the facility fees. In the United States, clinicians such as physicians, nurse practitioners (NPs), and physician assistants (PAs) can charge for their care delivery and are termed licensed independent provider (LIP) or qualified health providers (QHP). Centers for Medicare and Medicaid Services (CMS) refer to advanced practice provider (APPs) as nonphysician practitioners (NPP) and include both PAs and NPs.
Billing by LIPs is based on regulatory guidelines set up by various organizations such as the American Medical Association (AMA) for the current procedural terminology (CPT) billing codes, policies, and guidelines provided by the insurance companies. Since CMS, the US government is the main insurance provider for most critically ill patients in the United States, and their policies and guidelines largely determine LIP reimbursement. Other insurance companies can have policies for their patients that differ and need to be adhered to for reimbursement. In this article, we provide a review of the key terminologies, billing codes, policies and procedures for billing, and guidance for optimization of billing critically ill patients in the United States.
Billing for evaluation and management of the critically ill
Evaluation and management of a critically ill patient by a LIP can be billed based on the complexity of the patient managed, complexity of the care provided, time spent caring for the patient distinct from procedures performed and prevention of imminent deterioration. This billing can be done using either critical care billing codes or evaluation and management billing codes.
Billing for Critical Care Delivery
Documentation of critical care services provided and appropriate billing is an important aspect of patient care delivery that provides for communication, measurement of appropriateness of service provided, and revenue for sustainable practice. According to the AMA, critical care is the direct delivery by a physician(s) or other qualified health 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 patient’s 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 patient’s condition. Hence, billing for critical care to the patient needs to meet the requirements of this statement and with provision of supportive documentation.
The key components of documentation needed to justify billing for critical care services includes description of the patient’s critical care illness, the billing practitioner’s management of the critical illness demonstrating high complexity decision-making and medical necessity, and the time spent greater than 30 minutes. Time documented is the best estimate of time spent providing these services needs to be documented in discrete minutes (eg, 35 minutes), and neither as a range (30–45 minutes), nor in open ended terms (eg, >30 minutes). While the time includes review of patient records, it does not include time spent in review of literature or teaching trainees such as during rounds. Family discussions may be considered part of the critical care time when they are necessary to obtain patient information or to determine treatment decisions that are medically necessary for the patient’s care.
A single physician or NPP furnishes 30 to 74 minutes of critical care services to a patient on a given date with the CPT code 99291 for a given date. CPT code 99292 can be used for additional services provided in 30-minute time increments to the same patient for a given date, once the time spent exceeds 104 minutes. Critical care is typically furnished in a critical care area, which can include an intensive care unit (ICU) or emergency care facility, but are not restricted to those areas only. CMS and most of the insurers adopt the definition of critical care services in the CPT codebook and the CPT listing of bundled services for the reimbursement of these services provided to the patient. ,
If total critical care time on a calendar date is less than 30 minutes, critical care services are not billable, and the encounter should be reported using the appropriate evaluation and management (E/M) code. Only when critical care time totals 30 minutes or more may both critical care and a separate, nonoverlapping E/M service (before or after critical care) be reported if each is medically necessary and not duplicative. Modifier 25 (same-day significant, separately identifiable evaluation, and management service) can be appended on the claim when reporting these critical care services.
Critical care services can be delivered and billed for by LIPs who are qualified by education, training, licensure/regulation (when applicable) and facility privilege. Critical care requires the full attention of the practitioner 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. LIPs, in the same specialty and in the same group may provide concurrent follow-up care, such as a critical care visit subsequent to another practitioner’s critical care visit. For the critical care services where the time spent exceeds the threshold of 104 minutes, the time CPT code 99292 should be reported by a practitioner in the same specialty and group, in 30-minute increments. CMS allows billing for critical care billing as concurrent care (or concurrently) to the same patient on the same date by more than 1 practitioner in more than 1 specialty, if the service meets the definition of critical care and is not duplicative of other services. So, the same patient on the same date can be billed for critical care services by a cardiologist managing acute heart failure while the pulmonologist manages the acute respiratory failure requiring mechanical ventilation.
For care of surgical patients, 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. When the critical care service is unrelated to the procedure, modifier FT can be applied. When patient care is fully transferred from the surgeon to an intensivist for care delivery unrelated to the surgery, modifier FT (unrelated E/M) and 55 (postoperative management only) must be billed by the critical care practitioner to indicate the transfer of care. The surgeon can bill for their care using modifier 54 (surgical care only).
Evaluation and Management
Selection of the appropriate level of E/M services based on one of the following methods ( Table 1 ):
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The total time for E/M services performed on the date of the encounter.
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The level and complexity of the medical decision-making (MDM) for the services provided on the date of the encounter.
Table 1
Evaluation and management methodology and requirements
| Evaluation and Management Code | Time Spent (Minutes) | Level of Medical Decision-Making |
|---|---|---|
| Initial hospital inpatient care | ||
| 99221 | 40 or more | Low |
| 99222 | 55 or more | Moderate |
| 99223 | 75 or more | High |
| Subsequent hospital inpatient care | ||
| 99231 | 25 or more | Low |
| 99232 | 35 or more | Moderate |
| 99233 | 50 or more | High |
99221 to 99223 can be used for initial hospital inpatient care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low, moderate, and high level MDM (see Table 1 ). 99231 to 99233 is used for subsequent hospital inpatient care, per day, for the evaluation and management of a patient (see Table 1 ).
Guidelines for selecting level of service based on time
When time is used for reporting E/M services codes, the time defined in the service descriptors is used for selecting the appropriate level of services (see Table 1 ). It requires a face-to-face encounter with the physician or other qualified health professional and the patient and/or family/caregiver, but it can include time regardless of the location of the professional for additional activities related to the patient’s care.
These additional activities include the following:
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Preparing to see the patient, including obtaining and/or reviewing separately obtained history or test results,
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Performing a medically appropriate examination and/or evaluation,
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Counseling and educating the patient or the family,
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Ordering medications, tests, or procedures,
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Referring and communicating with other health care professionals (when not separately reported),
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Documenting clinical note in the electronic or other health record,
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Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver, and
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Care coordination not separately reported, (eg, with social worker or case manager).
The time spent should not include the following: the performance of other services that are reported separately, travel, and teaching that is general and not limited to discussion that is required for the management of a specific patient.
Guidelines for selection of the level of service based on medical decision-making
Four types of MDM are recognized: straightforward, low, moderate, and high. MDM includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. MDM is defined by the following 3 elements:
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The number and complexity of problem(s) that are addressed during the encounter.
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The amount and/or complexity of data to be reviewed and analyzed.
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The risk of complications and/or morbidity or mortality of patient management.
For the data review and analysis, 3 categories can of data are considered:
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Unique number of tests, documents, orders, or independent historian(s).
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Independent interpretation of tests (not separately reported).
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Discussion of management or test interpretation with an external physician or other qualified health professional (not separately reported).
The 4 levels of MDM (ie, straightforward, low, moderate, and high) and the 3 elements of MDM (ie, number and complexity of problems addressed at the encounter, amount and/or complexity of data reviewed and analyzed, and risk of complications and/or morbidity or mortality of patient management) need to meet the requirements to be used for E/M billing ( Table 2 ). To qualify for a particular level of MDM, 2 of the 3 elements for that level of MDM must be met or exceeded (see Table 2 ).
Table 2
Medical decision-making levels and elements
| Level of MDM | Problem Number and Severity | Data Reviewed | Risk of Complication |
|---|---|---|---|
| Straightforward |
|
Minimal | Minimal |
| Low |
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Low |
| Moderate |
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Moderate |
| High |
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High |
For inpatient Consultations, codes 99252, 99253, 99254, and 99255 can be used to report the care provided by a physician or other qualified health professional consultations provided to hospital inpatients. Only 1 consultation may be reported by a consultant per admission. Subsequent consultation services during the same admission are reported using subsequent inpatient hospital care codes (99231–99233).
The hospital inpatient or observation discharge day management codes, 99238 and 99239, are to be used to report the total duration of time on the date of the encounter spent by a physician or other qualified health professional for the final hospital day. 99238 can be used for time spent less than 30 minutes or lesser, and 99239 for time spent more than 30 minutes on the date of the encounter in preparation for discharge. The codes include as appropriate, final examination of the patient, discussion of the hospital stay, instructions for continuing care to all relevant caregivers and preparation of discharge records, prescriptions, and referral forms.
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Innovation, Technology, and Telemedicine in Critical Care
Pharmacists in Interprofessional Critical Care
ICU Capacity Management and Surge Preparedness
How to Start and Sustain a System-Based High-Reliability Medicine Venture for Your Critical Care Organization
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