Current Procedural Terminology (CPT) codes 99281-99285 are all emergency department visits for the Evaluation and Management (E/M) of a patient in the emergency department, excluding critical care services. No distinction is made between new and established patients in the emergency department. An emergency department is defined as an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. The facility must be available 24 hours a day.
CPT codes 99291 and 99292 are critical care codes used in the emergency department or other places in the hospital.
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. Note: 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.
CPT code 99292 is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care.
Physicians in the same group practice who have the same specialty may not each report CPT initial critical care code 99291 for critical care services to the same patient on the same calendar date. Medicare payment policy states that physicians in the same group practice who are in the same specialty must bill and be paid as though each were the single physician.
Medicare Policy:
1. Hospital emergency department services are not paid for the same date as critical care services when provided by the same physician to the same patient. (See the Medicare Claims Processing Manual, Chapter 12, Section 30.6.9.A)
2. Medicare advises physicians and qualified NPPs to retain documentation for discretionary review by the Medicare Administrative Contractor (MAC) should claims be questioned for both hospital care and critical care claims. The retained documentation must support claims for critical care when the same physician or physicians of the same specialty in a group practice report critical care services for the same patient on the same calendar date as other E/M services. (See the Medicare Claims Processing Manual, Chapter 12, Section 30.6.9.A)
3. Initial Hospital Care from Emergency Room: MACs pay for an initial hospital care service if a physician sees a patient in the emergency room and decides to admit the person to the hospital. They do not pay for both E/M services. Also, they do not pay for an emergency department visit by the same physician on the same date of service. When the patient is admitted to the hospital via another site of service; for example hospital emergency department, physician’s office, or nursing facility; all services the physician provides in conjunction with that admission are part of the initial hospital care when performed on the same date as the admission date. (See the Medicare Claims Processing Manual, Chapter 12, Section 30.6.9.1.A)
4. Critical Care Services and Other E/M Services Provided on Same Day: When the patient requires critical care services upon presentation to the hospital emergency department, only report critical care codes 99291 - 99292. Do not also report an emergency department visit code. (See the Medicare Claims Processing Manual, Chapter 12, Section 30.6.12.H)
5. When physicians provide critical care services on a date where an inpatient hospital, office, or outpatient E/M was furnished earlier on the same date at which time the patient did not require critical care, Medicare will allow and pay for both the critical care and the previous E/M service. (See the Medicare Claims Processing Manual, Chapter 12, Section 30.6.12.H)
6. Medically necessary critical care services provided on the same calendar date to the same patient by physicians representing different medical specialties that are not duplicative services are payable. The medical specialists may be from the same group practice or from different group practices. Critically ill or critically injured patients may require the care of more than one physician medical specialty. Concurrent critical care services provided by each physician must be medically necessary and not provided during the same instance of time. (See the Medicare Claims Processing Manual, Chapter 12, Section 30.6.12.I)
Clinical Example of Correct Billing of Time: A patient arrives in the emergency department in cardiac arrest. The emergency department physician provides 40 minutes of critical care services. A cardiologist is called to the emergency department and assumes responsibility for the patient, providing 35 minutes of critical care services. The patient stabilizes and is transferred to the Critical Care Unit (CCU). In this instance, the emergency department physician provided 40 minutes of critical care services and reports only the critical care code (CPT code 99291) and does not report codes for emergency department services. Using CPT code 99291, the cardiologist may also report the 35 minutes of critical care services provided in the emergency department. You report additional critical care services by the cardiologist in the CCU (on the same calendar date) using 99292 or another appropriate E/M code depending on the clock time involved. (See the Medicare claims Processing Manual, Chapter 12, Section 30.6.12.F)
Resources:
You may want to review the following information to help avoid errors regarding the reporting of critical care and emergency department services:
● Medicare Claims Processing Manual, Chapter 12, Section 30.6.9 and Section 30.6.9.1, which is at https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf
● Medicare Claims Processing Manual: Chapter 12, Section 30.6.12, Sections F, H, and I, which is at https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf
● MLN Matters Article, MM5993, Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292) https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM5993.pdf
● Medicare Fee for Service Recovery Audit Program, https://www.cms.gov/Research-Statistics-Dataand-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program
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