Apr 2000 Table of Contents

Getting Paid

A Critical Look at Critical Care Coding



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HCFA revised its coverage policies. Here's what you need to know if you provide critical care to Medicare patients.

Fam Pract Manag. 2000 Apr;7(4):14-15.

The Health Care Financing Administration (HCFA) has changed its payment structure and revised its coverage policies related to critical care. It reduced the relative value units (RVUs) assigned to critical care codes, clarified medical necessity criteria for critical care, defined the requirements for documenting time spent with family members and established documentation parameters for physicians caring for the same patient. HCFA took these actions in response to revisions made in the critical care codes, 99291 and 99292, by the CPT Editorial Panel (see “CPT Changes for 2000,” January 2000).

Why the change?

Among other changes, the CPT Editorial Panel deleted the word “unstable” and the phrase “requiring the constant attendance of the physician” from the descriptors for the critical care codes. From HCFA's perspective, the CPT changes make the work of critical care services more comparable to the work of lower-work-intensity evaluation and management (E/M) services and make it harder to distinguish critically ill patients from other patients.

For example, HCFA believes the treatment of patients with exacerbation of congestive heart failure, regardless of severity, could meet the new CPT definition of critical care. In HCFA's opinion, the care provided to many of these patients would more appropriately be coded as a non-critical-care E/M service. Thus, HCFA anticipates that a number of E/M services previously coded as noncritical care in 1999 will be coded as critical care in 2000.

Reduced RVUs

Based on this rationale, HCFA reduced the work RVUs of both critical care services by 10 percent for 2000. The work RVUs for 99291 went from 4.00 to 3.60, and the work RVUs for 99292 went from 2.00 to 1.80.

This means that, all other things being equal, HCFA is paying you less for critical care than it did in 1999. Indeed, even though the Medicare conversion factor increased between 1999 and 2000, HCFA is reimbursing less for critical care in 2000 because both the work and practice expense RVUs declined.

A policy clarification

In addition to changing the value of critical care services, HCFA issued a clarification of its critical care policy to the Medicare carriers for their use in medical review and other activities. Now, according to HCFA, establishing the medical necessity of critical care services as opposed to other E/M ser vices requires that the services meet the CPT definition of critical care plus two other criteria:

The clinical condition criterion requires that there be a high probability of “sudden, clinically significant or life-threatening deterioration in the patient's condition” that demands the highest level of physician preparedness to intervene urgently.

The treatment criterion says, “Critical care services require direct personal management by the physician. They are life- and organ-supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or failure to initiate, these interventions on an urgent basis would likely result in sudden, clinically significant or life-threatening deterioration in the patient's condition.”

HCFA notes that providing medical care to a critically ill patient does not automatically qualify as critical care. For example, if another physician is managing a patient who is maintained on a ventilator and nitroglycerin drip in the ICU and you treat a rash on that patient, you are not providing critical care. Likewise, as CPT notes, services for a patient who is not critically ill but who happens to be in a critical care unit do not qualify as critical care; you should use other E/M codes (e.g., subsequent hospital care codes) for such patients.

Time and documentation

Because the critical care codes are time-based, HCFA requires that you document the total time involved in providing critical care services. Any time spent with family members or other surrogate decision makers (either face-to-face or on the phone) to obtain a history or to discuss treatment options may count toward this time, if you meet three requirements:

  1. The patient is unable or incompetent to participate.

  2. The discussion is absolutely necessary for treatment decisions under consideration.

  3. The progress note includes documentation regarding the patient's inability or incompetence to participate, the necessity of the discussion, the treatment decision for which the discussion was needed, and the substance of the discussion as it related to the treatment decision.

Other family discussions (e.g., periodic update on the patient's condition, emotional support for the family) do not count toward critical care time. Likewise, as noted in CPT, you may not report as critical care any time spent in activities that occur outside the unit or off the floor, nor may you report any time spent in activities that do not directly contribute to the treatment of the patient.

Other points to ponder

Only one physician may bill for a given hour of critical care, even if more than one physician is providing care to a critically ill patient.

If you provide other services (e.g., endotracheal intubation) that are not bundled into the critical care codes, you may receive separate payment for those services. However, you will need to add a modifier –25 to the critical care codes to indicate that they were a significant and separately identifiable service provided on the same date.

If you are a teaching physician, you must be present for the period of time for which the claim is made. So, if you are billing for an hour of critical care in which you involved the services of a resident, you must have been present for the entire hour. You cannot count time spent teaching toward the critical care time, and you cannot count time spent by the resident in your absence.

Review and you'll be rewarded

If you provide critical care to Medicare patients, you may want to spend a few minutes reviewing the section of CPT that describes these services as well as the HCFA guidance mentioned in this article, which you can find online at www.hcfa.gov/pubforms/transmit/b994360.htm. Studying this information may make a critical difference in your Medicare reimbursements for such services.

Kent Moore is the AAFP'S manager of health care financing and delivery systems and a contributing editor to Family Practice Management.

Copyright © 2000 by the American Academy of Family Physicians.
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