Critical Care-Facility Charges for Hospital

shaspea

My facility is using a coding vendor who wants nursing to document critical care time like providers do. Our nurses document what they do, but don't currently summarize the amount of time they've been at the bedside. We currently use an Epic product and we're wondering if the Epic Flowsheet would help us. Does anyone else have this same issue and how have you solved it?

RHirsch

Did you ask why they wanted this? Physician critical care billing is totally different than facility billing, I don't see the reason to record minutes spent by an RN. This sounds fishy...

stmsmith

Is it because the patient has to be in the ED for a minimum number of minutes to charge for Critical Care?

trosi

99291 is defined as 1st 30-74 minutes of critical care. We use Epic nursing documentation, including the ED pt care timeline and flow sheets, in addition to the condition of the patient, to support the use of this code/charge.  If we cannot confidently code/charge 99291 we will code/charge 99285 instead.

RHirsch

Be careful - it seems there is a mixing of physician and facility fee billing of critical care. Physician is time based with acuity and facility is acuity based without regard to time. The codes are the same but the code choice is very different

trosi

For our internal hospital mapping of the ED E/M choices, we kept the 30 minute requirement for 99291.  Are you saying that we don't have to?  I do understand that the hospital has to have their own E/M mapping for the 99281-99285, which we do... but we always thought we "had" to keep the time requirement on the 99291 in our mapping as well.  Please advise.  Thanks!

RHirsch

Well, darn if you aren't right. I take back everything I said. There is no relationship between facility and doctor for 99281-99285 but time is used the same for both. But I would venture it is much easier for a facility to hit the 30 min mark than the doctor; the doctor comes in, runs the code then leaves. The RN is there much longer stabilizing the patient. 
Sorry!!!!!

stmsmith

Thanks.  I started to think I was crazy and was starting to panic if we had been doing something wrong.

trinker

We have actually run into situations where the facility did not meet the 30 minute threshold (the patient expired at 25 minutes) but the physician did and was able to charge for 30 minutes of critical care time,.  The physician can charge for time with family members, reviewing tests results and imaging reports and the facility does not.  We no longer use the physician documentation to determine if the 30 minute time frame has been met.

debs0906

I have a question regarding the carving out of services that are separately reportable. Per the parenthetical notes in the 2019 CPT book, it states, "Time spent performing separately reportable procedures or services should not be reported as critical care time". Once the patient hits the door and gets an IV the infusion services are chargeable. If you can't count the time spent with the patient during which an IV is running, how does one EVER hit the 30 minute mark? In the past we would not have carved out that time but based on the notes this year, it sounds like we should be. Any guidance or feedback would be much appreciated. 

bmelias

After comparing the language in the 2018 CPT book to 2019’s language for CPT 99291 there does not appear to be a change in the guidance for this code. While the facility must meet the time requirement stated in the code descriptor, facility coding for critical care differs from physician coding for critical care. An example of this difference in CPT code application appears in the Critical Care section Coding Tip for both the 2018 and 2019 CPT Code book. The Tip ‘Services Included in Critical Care Services’ states ‘For reporting by professionals, the following services are included in critical care when performed by the physician(s) providing critical care’ and goes on to list those services. The paragraph ends with ‘Any services performed that are not listed above should be reported separately. Facilities may report the above services separately.’

According to Medicare Claims Processing Manual, revised 5/16/19, Chapter 4, Section 160.1 ‘Critical Care Services’ at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf: ‘Under the OPPS, the time that can be reported as critical care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or critically injured patient.’ The situation you describe appears to meet that definition.