Awareness : OBC Tips

Billing Critical Care Services

When it comes to Medicare Part B physician services which paid under the physician fee schedule, critical care is not a service that is paid on a “shift” basis or a “per day” basis. Documentation may be requested for any claim to determine medical necessity.

Examples of critical care billing that may require further review could include: claims from several physicians submitting multiple units of critical care for a single patient, and submitting claims for more than 12 hours of critical care time by a physician for one or more patients on the same given calendar date.

Physicians assigned to a critical care unit (e.g., hospitalist, intensivist etc.) may not report critical care for patients based on a “per shift” basis. The CPT code 99291 is used to report the first 30 – 74 minutes of critical care on a given calendar date of service. It should only be used once per calendar date per patient by the same physician or physician group of the same specialty. CPT code 99292 is used to report each additional 30 minutes beyond the first 74 minutes of critical care.

It may also be used to report the final 15 – 30 minutes of critical care on a given date. Critical care of less than 15 minutes beyond the first 74 minutes or less than 15 minutes beyond the final 30 minutes, is not separately payable. Critical care of less than 30 minutes total duration on a given calendar date is not reported separately using the critical care codes. This service should be reported using another appropriate E/M code, such as subsequent hospital care.

If a physician or qualified NPP within a group provides “staff coverage” or “follow-up” for another group physician who provided the first hour of critical care services on that same calendar date, but has left the care to a second physician, the second group physician or qualified NPP should report the CPT critical care add-on code 99292 or another appropriate E/M code.