The principal idea behind this article is to summarize comprehensively yet concisely the 2022 CMS updates regarding the critical care services. I would encourage and urge all the members to read this section attentively to stay abreast with all the recent developments.
As a general reminder the two critical care services billing codes for the evaluation and management of the critically ill injured patients are:
99291: First 30-74 minutes
99292: Each additional 30 minutes
And, the five major changes for 2022 as proposed by the CMS for critical care services are:
1. It is allowed for the physicians and APPs in the same specialty to bill concurrent critical care services.
Previously, same specialty practitioners were required to bill and were paid as “one” when multiple practitioners provided services on the same date. Now, they can bill for critical care services as subsequent care or as aggregate time, and they are highlighted below with examples:
Subsequent care
Initial visit by a provider for 65 minutes (bill as 99291 as the first claim)
Subsequent visit at a later time on the same day for 60 minutes (bill as 99292 x2 as the second claim)
Aggregate time
Time of multiple practitioners in the same specialty can be added to meet 99291 or 99292. If Practitioner A spends 15 minutes of critical care, then 99291 cannot be billed; but, if Practitioner B spends 30 minutes of critical care, they can bill 99291 with a total time of 45 minutes as one claim
The prerequisites are that the visits are medically necessary, and each visit meets the definition of critical care.
2. Modifier FS needs to be used for split sharing of critical care services.
Previously, critical care services could not be split shared, but it can be done in 2022. The practitioner who provides the significant portion of the visit needs to bill. A significant or substantive portion is considered to be more than half the cumulative total time of both providers.
Example: The APP spends 20 minutes in critical care services and the physician spends 30 minutes. Total time spent is 50 minutes, and the physician may bill 99291.
Dr. Humayun Anjum
It is crucial to note that each provider needs to document a note for the medically necessary critical care that they personally performed and the time they spent. Additionally, upon review of the medical records, the two providers should be easily identifiable, and the medical record must be signed and dated by the provider who performed the substantive portion and billed.
Lastly, do not forget to submit the modifier FS.
3. Modifier 25 needs to be used to get paid for an ED visit or other E/M service on the same day as critical care.
Previously, hospital ED services were not paid on the same date as critical care by the same provider. But, in 2022, the practitioners may bill for ED visit at the hospital and also for other E/M services on the same day when there is supporting documentation. The practitioners will need to document that the E/M service was provided prior to the time when the patient did not require critical care, that the service was medically necessary, and that the service was separate and distinct with no duplication.
Of note, do not forget to submit the modifier 25.
4. Critical care visits will be separately billable from global surgery when unrelated with the use of modifier FT.
Previously pre- and postoperative critical care was included in the surgical package of many procedures with a global period of 10-90 days, and critical care visits would be paid only if the service was unrelated to the procedure. The concept remains the same in 2022 but, now, new modifier FT will need to be used to report critical care services unrelated to the procedure. Also, the service provided will need to meet the definition of critical care, which is usually above and beyond the procedure performed and should be unrelated to the specific injury or general surgical procedure performed.
5. There will be certain critical care medical record documentation requirements.
It is paramount that each practitioner must document the exact total critical care time and not a range or approximation of time. Additionally, it is equally as important for the documentation to indicate that the services provided were medically reasonable and necessary. In the setting of split/shared billing, the role of each practitioner should be clearly identifiable (the condition for which each practitioner treated the patient, how the care was concurrent either subsequent or aggregate, and the total time of each practitioner).
Hopefully, this review will provide a good perception for our members in regards to major updates for 2022, help them navigate the regulatory rules, and avoid any unnecessary setbacks. In the upcoming months, we will try to cover some more topics on practice management and administration, such as Medicare Physician Fee Schedule Rule, Hospital Outpatient Prospective Payment Rule, and coding/billing for teaching physicians, telehealth, and pulmonary rehabilitation services.