Critical Care Service Rule: Update for Surgery Billing

Defining Critical Care

Under CY 2022 Medicare physician fee schedule final rule, effective from January 1, 2022, critical care services can be billed as split/shared services. Before discussing the crucial care service rule, let’s define critical care services: the direct delivery by the physician or other 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 conditions. It involves high-complexity decision-making to treat single or multiple vital organ system failures and/or prevent further life-threatening deterioration of the patient’s conditions.

When to use critical care codes:

  • For the critically ill or unstable patient with a high probability of imminent or life-threatening deterioration
  • For critical care service 30 minutes or greater
  • The physician provides their full attention; cannot provide services to another patient at the same time
  • Total time spent on treatment of the patient should be documented; constant bedside attendance not required

When not to use critical care codes:

  • Patients who are in the postoperative global period and the critical care is related to the surgery
  • When critical care services do not equal or exceed 30 minutes; Report subsequent hospital care E/M code
  • Patients in the ICU or critical care unit who do not meet critical care requirements; Report as subsequent hospital care if unrelated to the global procedure

Split (or Shared) Critical Care Visits

Previous critical care rule: critical care services could not be billed as split/shared services. Effective from January 1, 2022, critical care services can be billed as split/shared services. Total critical care service time provided by a physician or NPP (same group/on the same calendar date) is summed. The practitioner who furnishes the substantive portion (>50%) of critical care time reports the service. Split/shared documentation requirements apply.

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).

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 activities are described in the prefatory language for critical care services in the CPT Codebook.

Critical Care Visits during a Surgical Global Period

Critical care may be separately reported during a global surgical period and billed if the critical care service is unrelated to the procedure. Preoperative and/or postoperative critical care can be paid in addition to the procedure if:

  • The patient is critically ill; and
  • The patient requires the full attention of the physician; and
  • Critical care is unrelated to the specific anatomic injury or general surgical procedure performed (e.g., trauma, burn cases)

While billing Medicare, the new modifier FT must be appended to the critical care services provided during a global period, no matter who is reporting the critical care. Modifier FT is defined as an unrelated E/M visit during a postoperative period, or on the same day as a procedure or another E/M visit. (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). Modifier FT should be now appended to the CPT codes 99291 and 99292 instead of modifiers 24 and 25 when critical care is provided within the global period procedure that is unrelated to the global service.

Documenting Critical Care

Documentation must indicate the total time spent by each reporting practitioner. Indicate that the services furnished to the patient where medically reasonable and necessary for the diagnosis or treatment of the patient’s critical care illness/injury. Modifier FT must be appended to critical care services provided during the global period. For concurrent care, indicate the role each practitioner played in the patient’s care (i.e., the conditions for which the practitioner treated the patient).

Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. We hope you got a basic understating of the critical care service rules. We shared this billing information for provider education, physicians are expected to understand payer policies and member’s medical benefits plans. In case of any assistance required in medical billing and coding, email us at: info@medicalbillersandcoders.com or call us at: 888-357-3226.

Reference: Critical Care Services