Critical Care Services Billing Update, January 1, 2023

CMS recently revised Critical Care billing rules effective January 1, 2023. The most significant requirements include:

• Split/Shared Services are now allowed and billed using a new FS modifier.
• Only one practitioner per specialty can submit a bill for critical care services (unchanged from prior years).
• The billing practitioner on a split/shared claim must be the practitioner who provided the substantive portion of the care, which is greater than 50% of the total time reported.
• 99292 may only be coded when a full 30 additional minutes are claimed.
• Physicians and NPPs (Non-Physician Practitioners) of the same specialty can combine times to meet all 30-minute thresholds (for 99291 and 99292). Care that is provided before midnight and continues uninterrupted into the next day is billed on the date the service originates. Services that are not continuous are billed on their respective dates.

Specific Billing and Documentation Requirements for Critical Care Split/Shared Services

Critical Care services can now be billed as split/shared services when physicians and NPPs from the same group furnish services for a patient on the same day. The aggregated practitioners’ critical care times determine if a 99291 and any 99292s may be billed. Prior to January 1, 2023, aggregated times could not be used to meet the 99291 or 99292 30-minute thresholds.

Reported critical care time must still be exclusive of any time spent jointly with other practitioners. Time spent jointly with another practitioner, whether they are the same or different types, may only be reported by one practitioner.

The 99291 billing practitioner is the practitioner who completed the substantive portion of care. The billing practitioner is based on which practitioner spent greater than 50% of the combined time reported (i.e., practitioner A will bill if their reported time is 16 minutes and practitioner B’s reported time is 15 minutes). If there are more than two practitioners who report critical care time, the one with the most time reported is the billing practitioner for that patient for that day. Combined critical care services time will be reported with the new FS modifier.

This billing process affords groups the opportunity to more frequently meet the 30-minute threshold for a 99291. A 99292 however, cannot be billed unless and until an additional full 30-minutes of care is furnished beyond 74 minutes of care (i.e., 104 minutes of critical care services must be furnished to bill 99291 and one 99292).

When critical care services are furnished by more than one practitioner of only one type (i.e., MD/MD, NPP/NPP), times are aggregated for billing purposes and the billing practitioner is the one who provides the substantive portion of the services on a particular date. In the event the practitioners individually document enough time to satisfy both a 99291 and 99292, both practitioners could bill on their respective portion of the claim; however, only one 99291 may be billed for each group each day regardless of time spent by each individual practitioner (e.g., if physician A documents at least 74 minutes and physician B reports at least 30 minutes, physician A would bill the 99291, and physician B would bill the 99292).

NPPs Are No Longer Their Own Specialty for Critical Care Services

Please note that while NPPs are usually considered their own specialty by CMS, beginning in 2022, NPPs are no longer considered their own specialty when they perform critical care services. They are defined as practicing in the same specialty as the physician with whom they are working. As a result, documentation of care provided by an NPP should include attribution to the specialty of the billing physician with whom the NPP works.

Critical Care Services by Different Group Practices

Practitioners with different group practices do not aggregate their times. Each group bills its own 99291’s and 99292’s for a given date. This is unchanged from prior years.

Each individual group, however, must now aggregate their times within their group to determine what is billed and who bills.

Critical Care Services that Carry into the Next Calendar Date

CMS has clarified that when critical care starts on one calendar date and continuously carries into another calendar date, the total time of critical care services will be billed on the date when the services began. It is important to clearly document whether the service was continuous. When documentation indicates that the services were not continuous, the total critical care time furnished on each calendar date must also be documented for billing purposes. In these scenarios, it is recommended that the documentation indicates that the time on the first calendar date has stopped and picked up thereafter on the next calendar date.

Evaluation and Management Code Bundling

As a reminder, Anesthesia CPT codes have a modifier indicator “0” bundling edit that prohibits unbundling of all E/M codes, except for 99291 and 99292¹, by a modifier and cannot be billed separately when performed on the same date. Attempts to unbundle will result in evaluation and management code denials. To avoid denials, coders should not separately bill any E/M codes, other than 99291 and 99292, on the same date when anesthesia services are furnished.  

Example: A critical care patient was consulted in the morning and later received anesthesia service for abdominal surgery. Integral services like placement of peripheral intravenous line or intraoperative interpretation of monitor function cannot be separately billed. E/M code for pain management also cannot be billed unless the operator’s primary specialty is pain management. Peripheral nerve blocks for post-operative pain management can be billed if the documentation supports billing the block separately with a modifier to unbundle the service.

Additional Considerations

• When bedside procedures are performed in conjunction with consultation, ICU consultation time should exclude procedure time. When these services occur, thoughtful documentation should be included to clearly delineate between these independent services.
• Consultations performed by NPPs should include proper modifiers and the total billed ICU consultation time should not exceed twenty-four hours or total shift time unless a continuous service is provided which spans two calendar days.²
• Private payer ICU billing rules may differ from Medicare rules. Always check for your specific contracted terms.

Here are examples of billing scenarios that may be applicable to a practice:

1. Medicare NCCI 2023 Coding Policy Manual – Chapter 2, Section B, #6 (https://www.cms.gov/files/document/medicare-ncci-policy-manual-2023-chapter-2.pdf)
2. US Department of Human and Health Services Office of Inspector General regularly publishes enforcement actions. Here’s the website for those interested: https://oig.hhs.gov/fraud/enforcement/

Contributor: DeeDee L. Culler, BS, CPC, COC, CEMC, CANPC