February 19, 2021 | By David Carpenter
Critical care billing is relatively simple. Documentation requires three items –
- The patient is critically ill.
- What the provider is doing to treat or prevent organ system failure or compromise.
- How much time the provider spent providing critical care.
While critical care billing is relatively simple, several minor details can allow providers to accumulate more billable time. The key to this is that critical care services are time-based. Any time spent in direct care for the patient is billable time.
Family decision-making. One frequently missed billable hour is the time spent discussing treatment options with family members when a patient is unable to make medical decisions. Medicare rules for family decision making require two items:
- That the patient is unable to participate in giving history and /or make treatment decisions, and
- The discussion is necessary to make treatment decisions.
Discussions to update family members who are not medical decision-makers are not billable. However, if the provider is present in the ICU where the patient is housed, phone discussions with family members who are medical decision-makers are counted as billable time.
Discussion of care with other medical professionals. Another source of often-missed billable time is discussing care with other medical professionals. The Medicare Claims Manual states:
“Time spent reviewing laboratory test results or discussing the critically ill patient’s care with other medical staff in the unit or at the nursing station on the floor may be reported as critical care, even when it does not occur at the bedside.”
For example, if a provider discusses treatment options with another specialist while on the unit, then this is billable time. Similarly, if a provider discusses a test or treatment over the phone while in the unit, this is billable time. A final scenario that providers frequently forget is patient sign-out (also called hand-off). Critical care has become a 24/7 business, with many hospitals moving to shift work. Sign-out from one shift to another counts as billable time for patients who are critically ill.
Follow-on care by multiple providers. Billing during sign-out brings up another area of critical care billing that is frequently misunderstood. Medicare discusses follow-on care as:
“A physician or qualified NPP within a group provides ‘staff coverage’ or ‘follow-up’ for each other after the first hour of critical care services was provided on the same calendar date by the previous group clinician (physician or qualified NPP), the subsequent visits by the ‘covering’ physician or qualified NPP in the group shall be billed using CPT critical care add-on code 99292.”
Key to this is the statement that “Concurrent critical care services provided by each physician must be medically necessary and not provided during the same instance of time.”
For example, when two providers are signing out, only one provider can bill for critical care time. Critical care groups should develop protocols to allocate the critical care time to either incoming or outgoing shifts. Similarly, during rounds, if an Advanced Practice Provider (APP) and physician discuss the patient, only one provider may bill for the time spent. Another common situation is during an emergency. For example, during a cardiac arrest, the physician could bill for CPR (CPT 92950) while the APP bills for performing the intubation (CPT 31500). Close cooperation when performing follow-on care is crucial to billing critical care directly. Also, documentation that any critical care is nonconcurrent will decrease denials.
At its core, critical care billing is relatively simple. However, paying close attention to family updates, collaboration with other medical professionals, and follow-on care will allow the maximum amount of critical care time to be documented and appropriately billed for.
 Medicare Claims Processing Manual, Chapter 12 – Physician/Nonphysician Practitioners, (Rev. 10356, 09-18-20) pg. 53. (https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf)
 Ibid. pg. 51.
 Ibid pg. 56.