Billing Guidelines for Anesthesiologists Performing Critical Care and Related Services

During the COVID-19 National Health Emergency, many anesthesiologists are being tapped for patient care duties outside of their normal scope, especially while so many elective and non-critical surgeries and procedures have been postponed.

Because of their experience providing critical care for patients during surgeries, anesthesiologists are particularly finding a place caring for patients in the ICU. Some may serve as intensivists, providing evaluation and management of patient care and even critical care services. Or they may be assisting staff intensivists by performing ancillary services, like intubations, ventilator management, invasive lines, etc. While caring for patients is their first priority, anesthesiologists also want and need to be paid for their services. Here are a few tips for billing for critical care or other related services.

Documentation Is Key

The first step for ensuring proper payment for the work anesthesiologists do is proper documentation. Generally physicians should document all procedures performed, medical necessity indicators, diagnostic or exam findings used to confirm medical necessity, other interventions attempted, how the procedure was performed, any supplies used, success or failure of the procedure, any tests done to confirm the procedure, date and time, and signature.

Condition of the Patient

For critical care procedures, the condition of the patient, the level of care management, and the time spent are all critical components to be recorded. For instance, in order for critical care services to be billed, the patient must have “a critical 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.” Such an illness or injury should be thoroughly documented.

High Complexity of Decision Making

As well, critical care also involves “high complexity decision making to assess, manipulate, and support vital system functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.” This is a higher threshold of care than for other evaluation and management services. According to CMS, critical care typically “requires interpretation of multiple physiologic parameters and/or application of advanced technology(s),” though it may also be provided “in life threatening situations when these elements are not present.” Physicians should document all findings and how they contribute to medical decision making and patient care.

Time Spent

Finally, critical care includes a specified amount of time, during which the physician is devoting his full attention to the patient’s care. According to CMS, critical care time “must be spent at the immediate bedside or elsewhere on the floor or unit so long as the physician is immediately available to the patient.” The time spent can include reviewing test results, discussing care with nursing staff or other physicians in person or by telephone, writing orders and completing other paperwork, arranging transfer to another facility for emergent care, and discussing care (in person or by phone) with family members in the event the the patient is unable to give a history and/or make treatment decisions. As well, critical care time can be continuous or broken up into multiple sessions, but it must be documented.

If the patient’s condition and the level of care by the physician otherwise meet the requirements of critical care but the physician does not devote at least 30 minutes to the patient, then another E&M code should be chosen. However, if the patient condition and the level of care warrant the critical care designation, and the physician spends at least 30 minutes of full attention on the patient’s care, then 99291 should be billed for the first hour (30-74 minutes) and 99292 should be billed for each subsequent half hour. Again, all time should be documented in the medical record.

Procedures Bundled with Critical Care

Some procedures are bundled with critical care and should not be billed separately, including the following:

The interpretation of cardiac output measurements (CPT 93561, 93562);
Chest x-rays, professional component (CPT 71010, 71015, 71020);
Blood draw for specimen (CPT 36415);
Blood gases, and information data stored in computers (e.g., ECGs, blood pressures, hematologic data-CPT 99090);
Gastric intubation (CPT 43752, 91105);
Pulse oximetry (CPT 94760, 94761, 94762);
Temporary transcutaneous pacing (CPT 92953);
Ventilator management (CPT 94002 – 94004, 94660, 94662); and
Vascular access procedures (CPT 36000, 36410, 36415, 36591, 36600)

Separately Billable Procedures

Any other procedures performed can be billed separately to payers, including emergency intubations (31500), A-line placement (36620), CVP placement (36556), and Swan-Ganz placement (93503). Just be sure to document the procedures thoroughly, including a note that the time spent on these procedures was not included in the total time spent providing critical care services.

Modifier -22 may be warranted for some procedures where “substantially greater” work is required to avoid exposure to COVID-19. According to WPS-GHA, Indiana’s Medicare Administrative Contractor, this modifier should be used for “surgeries where services performed are significantly greater than usual,” though “additional time alone does not justify the use of this modifier.”

When Modifier -22 is billed to Medicare, an Additional Documentation Request (ADR) letter will be sent requesting medical records to support the use of the 22 Modifier. It is important that both an operative report and a separate concise statement on why it was beyond the normal difficulty be returned with a copy of the ADR letter. Failure to submit the statement and documentation in a timely fashion will result in processing of the claim without Modifier -22.

WPS-GHA also provides the following recommendations for documenting the additional work required: “When developing a separate statement avoid using a generalized statement. Comments like ‘patient was obese’ or ‘surgery took longer than usual’ or ‘multiple adhesions’ lack specific details which identify why the procedure was beyond the normal difficulties that could be encountered with the procedure. Further, it is important that your operative note supports the statement on why the surgical procedure was beyond the ordinary range of difficulty.”

Will Anesthesiologists Be Paid for Critical Care and Related Services?

Some anesthesiologists are worried they won’t be paid for these services since they don’t typically perform them. Should they be concerned? It doesn’t seem like it, based on information currently available.

For one, the American Society of Anesthesiologists recently published an article outlining how to bill for critical care services, without offering any caveats for possible nonpayment. In fact, that organization has advocated for years that anesthesiologists are well-trained in critical care management and could be utilized for such services {AUTOMATIC DOWNLOAD}.

“People are now seeing that anesthesiologists are critical care medicine physicians. We deal with patients in the OR, and now we are happy to help in the ICU to manage patients,” said Mary Dale Peterson, MD, president of the American Society of Anesthesiologists (ASA), and executive vice president and chief operating officer of Corpus Christi, Texas-based Driscoll Health System, for an article at Health Leaders.

As well, no speciality or taxonomy distinction has been made in the Medicare Claims Processing Manual for billing critical care services, nor was any distinction made in the COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing. In fact, billing guidelines for critical care services were expanded under Medicare’s temporary telehealth guidelines, and even non physician practitioners are allowed to bill Medicare for critical care services if allowed under state scope of practice guidelines.

More Information

Are you or physicians in your practice being called on to provide critical care and other related services? Now is the time to refresh your knowledge on necessary documentation and billing requirements. For more information, check out these resources: