OIG Turns Attention Toward Critical Care Billing

According to an August announcement, critical care services billed to Medicare are on the radar of the Office of Inspector General for review beginning in 2019.

Both CPT and Medicare offer specific guidelines for what kinds of conditions qualify for critical care services. Namely, critical care services are those performed on patients with a critical illness or injury, which CPT defines as “an illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.”  Critical care services are defined as “a physician’s direct delivery of medical care for a critically ill or critically injured patient. It involves decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.” As well, Medicare adds the stipulation that “the 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.”

While the patient’s condition and the services provided must be documented properly to bill for critical care services, the service is time-based. According to the American College of Emergency Physicians (ACEP), that means physicians must spend at least 30 minutes “evaluating, managing, and providing care to the critical patient, as well as time spent in documenting such activities,” whether at the patient’s bedside or elsewhere. The time may be intermittent or continuous, but “during each moment of this accrued total time, the physician must devote full attention to the particular patient.” As well, time spent performing procedures not bundled with critical care services must be carved out of the total critical care time.

The CPT code 99291 is used to bill for the first 30-74 minutes of critical care services. Once the physician spends more than 74 minutes, CPT code 99292 is used for each additional 30 minutes of care.

In the Medicare Learning Network’s MLN Matters #MM5993, the Centers for Medicare and Medicaid Services (CMS) offered the following chart to highlight the time-based billing for critical care services.

According to the OIG, their review will focus on whether Medicare patients billed for critical care services met the criteria for critical illness or injury, and whether the time requirements  were met to “determine whether Medicare payments for critical care are appropriate and paid in accordance with Medicare requirements.”

Because the time-based element is so crucial in billing critical care services, ACEP recommends that emergency physicians take special care in documenting the time spent.

“Clinical reassessments and documentation must support the amount of critical care time aggregated and should include a description of all of the physician’s interval assessments of the patient’s condition, any ‘impairments of organ systems’ based on all relevant data available to the physician (i.e. symptoms, signs and diagnostic data), the rationale and timing of interventions and the patient’s response to treatment,” ACEP advises. “It is recommended that the physician note ‘the time involved in the performance of separately reportable procedures was not counted toward critical care time.’ Failure to do so might result in the critical care time being reduced by payers to account for any concurrent separately billable services.”

To learn more about how to bill for critical care that crosses over into a second day, which services are bundled into the critical care code and which are not, and how Medicare differs from CPT in their guidelines for billing critical care services, review ACEP’s Critical Care FAQ webpage.

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