Clinical Example for Critical Care

Clinical Examples - Critical care services

An 85-year-old male patient is admitted to the intensive care unit following abdominal aortic aneurysm resection. Two days after surgery he requires fluids and pressors to maintain adequate perfusion and arterial pressures. He remains ventilator-dependent.

A 66-year-old female patient is 4 days status post mitral valve repair. She develops petechiae, hypotension, and hypoxia requiring respiratory and circulatory support.

A 72-year-old male admitted for right lower lobe pneumococcal pneumonia with a history of COPD becomes hypoxic and hypotensive 2 days after admission.

A 58-year-old admitted for an acute anterior wall myocardial infarction continues to have symptomatic ventricular tachycardia that is marginally responsive to antiarrhythmic therapy

Clinical Examples - Non Covered Critical care services

The Patients admitted to a critical care unit because no other hospital beds were available.

The Patients admitted to a critical care unit for close nursing observation and/or frequent monitoring of vital signs (e.g., drug toxicity or overdose).

The Patients admitted to a critical care unit because hospital rules require certain treatments (e.g., insulin infusions) to be administered in the critical care unit.

Example: 

A dermatologist evaluates and treats a rash on an ICU patient who is maintained on a ventilator and nitroglycerine infusion that is being managed by an intensive visit. The dermatologist should not report service for critical care.

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New Lab Codes Effective July 1, 2021

The New HCPCS Lab Codes are released which is Effective from July 1, 2021. These new codes are contractor-priced (where applicable) until they are nationally priced and undergo the CLFS annual payment determination process. 

The MACs will only price PLA codes for laboratories within their jurisdiction. and Type of Service (TOS) for all the codes should be "5".

0248U - Oncology (brain), spheroid cell culture in a 3D microenvironment, 12 drug panel, tumor-response prediction for each drug.

0249U - Oncology (breast), semiquantitative analysis of 32 phosphoproteins and protein analytes, includes laser capture microdissection, with algorithmic analysis and interpretative report.

0250U - Oncology (solid organ neoplasm), targeted genomic sequence DNA analysis of 505 genes, interrogation for somatic alterations (SNVs [single nucleotide variant], small insertions and deletions, one amplification, and four translocations), microsatellite instability and tumor-mutation burden.

0251U - Hepcidin-25, enzyme-linked immunosorbent assay (ELISA), serum or plasma.

0252U - Fetal aneuploidy short tandem–repeat comparative analysis, fetal DNA from products of conception, reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplications, mosaicism, and segmental aneuploidy.

0253U - Reproductive medicine (endometrial receptivity analysis), RNA gene expression profile, 238 genes by nextgeneration sequencing, endometrial tissue, predictive algorithm reported as endometrial window of implantation (eg, pre-receptive, receptive, post-receptive).

0254U - Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using embryonic DNA genomic sequence analysis for aneuploidy, and a mitochondrial DNA score in euploid embryos, results reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplications, mosaicism, and segmental aneuploidy, per embryo tested.

G0327 - Colorectal cancer screening; blood-based biomarker.

Critical Care Guidelines - CPT 99291 and 99292

Critical care is the direct delivery by a physician(s) or other qualified health care professional of medical care for a critically ill or critically injured patient.

A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition. 

Critical care services include the treatment of vital organ failure or prevention of further life-threatening conditions. 

Delivering medical care in a moment of crisis and in time of emergency is not the only requirement for providing Critical Care services.

Examples of vital organ system failure include, but are not limited to,

• Central nervous system failure, 
• Circulatory failure, 
• Shock, 
• Renal, hepatic, metabolic, and/or respiratory failure. 

Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patient's condition continues to require the level of attention mentioned above.

Key Points

The Critical Care Services for a patient who is not critically ill but happens to be in a critical care unit are reported using other appropriate E/M codes.

Critical care and other E/M services may be reported to the same patient on the same date by the same individual.

The critical care code is applicable for a critical care service provided for the first 30 – 74 minutes. Any Critical Care service provided for less than 30 minutes should be billed with the appropriate level of E/M code.

Usually, a Critical Care service is provided to a patient in a "Critical Care Area" such as,

• Coronary Care Unit (CCU), 
• Intensive Care Unit (ICU), 
• Respiratory Care Unit, or 
• Emergency Room.

Included Services

The mentioned below list of services are included when performed during the "Critical Care service"

• Interpretation of cardiac output measurements - 93561, 93562
• Chest X rays -71045, 71046
• Pulse oximetry - 94760, 94761, 94762[blood gases, and collection and interpretation of physiologic data] (eg, ECGs, blood pressures, hematologic data);
• Gastric intubation - 43752, 43753
• Temporary transcutaneous pacing - 92953 
• Ventilatory management - 94002-94004, 94660, 94662 
• Vascular access procedures - 36000, 36410, 36415, 36591, 36600

Any services performed that are not included in this listing should be reported separately. Facilities may report the above services separately.

Tips

Inpatient critical care services provided to neonates (28 days of age or younger) are reported with the neonatal critical care codes 99468 and 99469. 

Inpatient critical care services provided to infants 29 days through 71 months of age are reported with pediatric critical care codes 99471-99476

To report critical care services provided in the outpatient setting (eg, emergency department or office), for neonates and pediatric patients up through 71 months of age, see the critical care codes 99291, 99292

Click here to check TCM

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Transitional Care Management (TCM) Guidelines

The CPT Codes 99495 and 99496 are used to report transitional care management services (TCM).

These services are covered for a new patient or established patient and the code selection will be considered based on the MDM and the problems require either "Moderate Complexity or High Complexity".

To qualify for Transitional Care Management (TCM) services, the patient must be discharged from one of the following facility settings,

•  Acute Care Hospital
•  Psychiatric Hospital
•  Rehabilitation Facility
•  Long-term Care Hospital
•  Skilled Nursing Facility
•  Partial hospitalization
•  Hospital outpatient observation
•  Partial hospitalization at a community mental health center

Additionally, the patient must be returned to one of the following community settings,

•  Home
•  Domiciliary (e.g., group home or boarding house)
•  Nursing Facility (e.g., boarding home or adult care home)
•  Assisted Living Facility

Guidelines

• TCM is included in one face-to-face visit within the specified time-frames, in combination with non-face-to-face services that may be performed by the physician or other qualified health care professional.

• Only one individual may report these services and only once per patient within 30 days of discharge.

• Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within 30 days.

• The same individual should not report TCM services provided in the postoperative period of a service that the individual reported.

Non-Face To Face Service

Non-face-to-face services provided by the physician or other qualified health care provider may include,

• Obtaining and reviewing the discharge information (eg, discharge summary, as available, or continuity of care documents).

• Reviewing the need for or follow-up on pending diagnostic tests and treatments.

• Interaction with other qualified health care professionals who will assume or reassume care of the patient's system-specific problems.

• Education of patient, family, guardian, and/or caregiver.

• Establishment or reestablishment of referrals and arranging for needed community resources.

• Assistance in scheduling any required follow-up with community providers and services.

The first face-to-face visit is part of the TCM service and not reported separately. 

Additional E/M services provided on subsequent dates after the first face-to-face visit may be reported separately. 

Interactive Communication

For TCM requires interactive contact with the patient or caregiver, as appropriate, within two business days of discharge and the communication typically involves following,

1. In-person visits: Face-to-face visits with the healthcare provider allow for a more comprehensive assessment of the patient's health status and the ability to address any issues that may arise. 
2. Telephone calls: Providers may call patients or caregivers to discuss the patient's condition, medications, follow-up appointments, and any other necessary information.
3. Secure messaging: Some healthcare providers use secure messaging platforms to communicate with patients, allowing for quick and convenient exchange of information.
4. Video visits: Telehealth visits via video conferencing can be used to conduct follow-up visits, assess the patient's progress, and address any concerns.

CPT Codes

• CPT 99496 -The face-to-face visit must occur within 7 calendar days of the date discharge and MDM must be of "High complexity". 

• CPT 99495 -  The face-to-face visit must occur within 14 calendar days of the date of discharge and MDM must be "Moderate complexity".

Documentation

For Transitional Care Management (TCM) services, the following elements must be documented in the patient's record:

1. Date of discharge from acute care
2. Date of provider contact with the patient (two days post-discharge)
3. Date of face-to-face visit with the provider (either 7 days or 14 days post-discharge)
4. Complexity of the Medical Decision Making (MDM), documented as either moderate or high

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Online Digital Evaluation e-visits

Guidelines

• Online digital evaluation and management (E/M) services (99421, 99422, 99423) are patient-initiated services with physicians or other qualified health care professionals (QHPs). 

• It requires a physician or other QHP's evaluation, assessment, and management of the patient. 

• These services are not for the nonevaluative electronic communication of test results, scheduling of appointments, or other communication that does not include E/M. 

• While the patient's problem may be new to the physician or other QHP, the patient is an established patient. 

• Patients initiate these services through Health Insurance Portability and Accountability Act (HIPAA)-compliant secure platforms, such as electronic health record (EHR) portals, secure email, or other digital applications, which allow digital communication with the physician or other QHP.

• Online digital E/M services are reported once for the physician's or other QHP's cumulative time devoted to the service during a seven-day period. 

• Physician's or other QHP's cumulative service time includes a review, Initial inquiry,  review of patient records or data pertinent to an assessment of the patient's problem, 

• The personal physician or other QHP interaction with clinical staff focused, the patient's problem, development of management plans, 

• Including physician- or other QHP generation of prescriptions or ordering of tests, and subsequent communication with the patient through online, telephone, email, or other digitally supported communication, which does not otherwise represent a separately reported E/M service. 

• When the online digital inquiry is related to a surgical procedure and occurs during the postoperative period of a previously completed procedure, then the online digital E/M service is not reported separately. 

• When the patient generates the initial online digital inquiry for a new problem within seven days of a previous E/M visit that addressed a different problem, then the online digital E/M service may be reported separately. 

• When the patient presents a new, unrelated problem during the seven-day period of an online digital E/M service, then the physician's or other QHP's time spent on evaluation, assessment, and management of the additional problem is added to the cumulative service time of the online digital E/M service for that seven-day period.

Physicians

• CPT 99421 - Online digital evaluation and management service, for an established patient, for up to 7 days, a cumulative time during the 7 days; 5-10 minutes

• CPT 99422 - CPT 99421 - Online digital evaluation and management service, for an established patient, for up to 7 days, a cumulative time during the 7 days; 11-20 minutes

• CPT 99423 - CPT 99421 - Online digital evaluation and management service, for an established patient, for up to 7 days, a cumulative time during the 7 days; 21 or more minutes

Non-physicians (NP & PA)

• CPT 98970 - Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, a cumulative time during the 7 days; 5-10 minutes

• CPT 98971 - Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, a cumulative time during the 7 days; 11-20 minutes

• CPT 98972 - Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, a cumulative time during the 7 days; 21 OR more minutes

2021 E&M Changes

COVID - 19 Vaccine Updates - May'2021

The FDA is recommended to use "Pfizer-BioNTech" COVID-19 vaccine for adolescents aged 12-15 years.  

On May 12, 2021, the Advisory Committee on Immunization Practices (ACIP) recommended the use of the "Pfizer-BioNTech" COVID-19 vaccine in adolescents aged 12-15 years, and CDC Director Rochelle Walensky adopted this ACIP recommendation.

All COVID-19 vaccination providers are directed and required to make available and administer COVID-19 vaccine to all persons eligible to receive the COVID-19 vaccine consistent with the applicable Emergency Use Authorizations for such products.   

The COVID-19 vaccines themselves are free to everyone 12 years and older in the United States, but providers incur costs associated with administering them, training staff, and storing the vaccine. 

If these services are not covered by a patient’s health plan or only partially covered, providers are not allowed to balance bill the patients.

Claims for reimbursement will be priced as described below for eligible services,

Vaccine administration fees will be priced based on national Medicare rates for administering the COVID-19 vaccine (not geographically adjusted) and are outlined below,

For dates of service through March 14, 2021:-

• Administration of a single-dose COVID-19 vaccine - $28.39

• Administration of the first dose of a COVID-19 vaccine requiring a series of two or more doses - $16.94

• Administration of the final dose of a COVID-19 vaccine requiring a series of two or more doses - $28.39

For dates of service on or after March 15, 2021:-

• Administration (per dose) of a COVID-19 vaccine - $40.00

• Reimbursement will be based on the incurred date of service.

Click here for COVID-19 Lab Code Updates

Cognitive Assessment and Care Plan - Guidelines

Cognitive assessment and care plan services are provided when a comprehensive evaluation of a new or existing patient, who exhibits signs and/or symptoms of cognitive impairment, is required to establish or confirm a diagnosis, etiology, and severity for the condition.

Do not report cognitive assessment and care plan services if any of the required elements are not performed or are deemed unnecessary for the patient’s condition

A single physician or other qualified health care professional should not report 99483 more than once every 180 days.

CPT code 99483 provides reimbursement to physicians and other eligible billing practitioners for a comprehensive clinical visit that results in a written care plan

Eligible Provider

Any provider is eligible to report E/M services can provide this service. Eligible providers include physicians MD and DO, nurse practitioners, clinical nurse specialists, and physician assistants. 

Eligible practitioners must provide documentation that supports a moderate-to-high level of complexity in medical decision making, as defined by E/M guidelines.

The provider must also document the detailed care plan developed as a result of each required element covered by 99483

Required Elements to bill CPT 99483

CPT 99483 - Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home, with all of the following required elements,

• Cognition-focused evaluation including a pertinent history and examination.

• Medical decision-making of moderate or high complexity.

• Functional assessment (eg, basic and instrumental activities of daily living), including decision-making capacity.

• Use of standardized instruments for the staging of dementia (eg, functional assessment staging test [FAST], clinical dementia rating [CDR]).

• Medication reconciliation and review for high-risk medications.

• Evaluation for neuropsychiatric and behavioral symptoms, including depression, including use of standardized screening instrument(s).

• Evaluation of safety (eg, home), including motor vehicle operation.

• Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks.

• Development, updating or revision, or review of an Advance Care Plan.

• Creation of a written care plan, including initial plans to address any neuropsychiatric symptoms, neurocognitive symptoms, functional limitations, and referral to community resources as needed (eg, rehabilitation services, adult day programs, support groups) shared with the patient and/or caregiver with initial education and support.

• Typically, 50 minutes are spent face-to-face with the patient and/or family or caregiver.

Many of the required assessment elements can be completed by appropriately trained members of the clinical team working with the eligible provider. 

Assessments that require the direct participation of a knowledgeable care partner or caregivers, such as a structured assessment of the patient’s functioning at home or a caregiver stress measure, may be completed prior to the clinical visit and provided to the clinician for inclusion in care planning. 

Care planning visits can be conducted in the office or other outpatient, home, domiciliary, or rest home settings.

Qualified health care professionals may report 99483 as frequently as once per 180 days

Tips

Do not report 99483 in conjunction with the following CPT codes,

• E/M services - 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99366, 99367, 99368, 99497, 99498.

• Psychiatric diagnostic procedures 90785, 90791, 90792.

• Brief emotional/behavioral assessment - 96127.

• Psychological or neuropsychological test administration 96146. 

• Health risk assessment administration 96160, 96161.

• Medication therapy management services 99605, 99606, 99607.

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