The 2022 Medicare Physician Fee Schedule Final Rule contained significant revisions for proper reporting of critical care services. The changes included revised instructions for reporting critical care when rendered by multiple providers within the same group and specialty as well as revised instructions for time based reporting of critical care that directly conflict with the instructions in contained in CPT.
TIME-BASED REPORTING OF CRITICAL CARE
From a CPT coding perspective, an initial critical care service may be reported when critical care services are rendered and the documentation supports at least 30 minutes of critical care were provided. The initial service code includes critical care time spent up to 74 minutes. Historically, both CPT and CMS allowed the reporting of an add-on critical care code to describe each additional 30 minutes spent performing critical care with no minimum time threshold. However, in the 2022 Final Rule, CMS modified their billing requirements to no longer allow the add-on code unless 30 additional minutes of critical care are provided.
The 2022 CPT manual provides the following references for the appropriate reporting of critical care:
| Less than 30 minutes | Appropriate E/M codes |
| 30-74 minutes | 99291 x 1 |
| 75-104 minutes | 99291 x 1 AND 99292 x 1 |
| 105-134 minutes | 99291 x 1 AND 99292 x 2 |
| 135-164 minutes | 99291 x 1 AND 99292 x 3 |
| 165-194 minutes | 99291 x 1 AND 99292 x 4 |
| 195 minutes or longer | 99291 and 99292 as appropriate |
Based on the CMS instructions for appropriate reporting of critical care, the following time based thresholds would be as follows:
| Less than 30 minutes | Appropriate E/M codes |
| 30-74 minutes | 99291 x 1 |
| 104 minutes minimum | 99291 x 1 AND 99292 x 1 |
| 135 minutes minimum | 99291 x 1 AND 99292 x 2 |
| 166 minutes minimum | 99291 x 1 AND 99292 x 3 |
| 197 minutes minimum | 99291 x 1 AND 99292 x 4 |
| 228 minutes | 99291 x 1 AND 99292 x 5 |
CONCURRENT CRITICAL CARE BY PROVIDERS OF THE SAME SPECIALTY WITHIN THE SAME GROUP
CMS also issued the following notable guidelines:
- CPT 99291 may not be reported more than once per date of service by providers of the same specialty within the same group.
- In instances where a provider initiates critical care services but does not meet the 30 minute minimum threshold and another provider of the same specialty within the same group continues critical care services, the times may be aggregated together for purposes of reporting critical care.
- In instances where both a NPP and physician are involved in providing critical care on the same date of service, the critical care services must be billed in accordance with the split/shared guidelines, regardless of when the services occur.
RECOMMENDATIONS
These changes are significant and are likely to result in significant billing errors to the Medicare program. We recommend taking a proactive approach to mitigate the risk to your organization. We recommend providing education and training to your providers and coders, implementing system edits and alerts, conducting auditing and monitoring and revising your coding policies and procedures. The HBE documentation and coding experts are available to assist you with these efforts.
The Final Rule is located here: https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-federal-regulation-notices/cms-1751-f
The manual instructions are located here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
The FAQs are located here: https://www.cms.gov/files/document/faqs-split-or-shared-visits-and-critical-care-services.pdf
DISCLAIMER: This newsletter contains only summary information and highlights; it should be read in conjunction with the full article or document provided as a link. Any advice or recommendations are general and specific questions should be directed to professional counsel.