Critical Care Services

Transcription

1 Critical Care Services MEHIMA Spring Meeting March 17, 2016 Dianne Rodrigue, PA, MHP, CCDS, CPC Disclaimer This presentation is for general education purposes only. The information contained in these materials and presented during the lecture or in response to your questions is not intended to be, and is not, legal advice. The laws and regulations at issue in this lecture may be open to interpretation. This information may not be copied, reproduced, dismantled, quoted, or presented without the expressed written approval of BNN. No part of this presentation may be reproduced, stored in a retrieval system or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording, or taping) without the expressed written permission from BNN. 2

2 Objectives Review definition of critical care services CMS and CPT Identify the key documentation and coding requirements Medical Necessity and Time Clarify guidelines for reporting critical care services as a teaching physician and for Non- Physician Providers (NPPs) 3 Critical Care Definition 4

3 Definition Direct delivery by physician(s) or other qualified health care professional of medical care for a critically ill or injured patient. Critical illness or injury that 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, i.e. urgent care. Critical intervention involves decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient s condition. 5 Definition Examples of vital organ system failure include, but are not limited to: Central Nervous System (CNS) failure Circulatory failure Shock Renal, hepatic, metabolic and/or respiratory failure 6

4 Definition Critical care is not predicated on place of service, i.e. consider patient s condition and intensity of service, not patient location. Treatment and management of the patient s condition, while not necessarily emergent, shall be required based on the threat of imminent deterioration. 7 Clinical examples (CMS) that may warrant critical care services 67 year old female 3 days status post mitral valve repair, develops petechiae, hypotension and hypoxia requiring respiratory and circulatory support. 70 year old admitted for RLL pneumococcal pneumonia with history of COPD, becomes hypoxic and hypotensive 2 days after admission requiring respiratory and circulatory support. 81 year old male admitted to the intensive care unit following AAA resection. Two days after surgery he requires fluids and pressors to maintain adequate perfusion and arterial pressures. He remains ventilator dependent. 8

5 Clinical examples (CMS) which may not warrant critical care services Daily management of patient on chronic ventilator therapy Management of dialysis or care related to dialysis for ESRD Patients admitted to a critical care unit for close nursing observation and/or frequent monitoring of vital signs (e.g., drug toxicity or overdose) Patients admitted to a critical care unit because hospital policy requires certain treatments to be administered in the critical care unit (e.g. insulin or other drug infusions) 9 Critical Care Services and Medical Necessity Social Security Act 1862(a)(1)(A) All billed services must be based only on activities that are reasonable and necessary for the diagnosis or treatment of illness or injury. CMS Pub 100-4, Chapter 12, Subsection Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. 10

6 Supporting medical necessity 1. Is the patient critically ill, i.e. life threatening scenario? 2. Were interventions performed using high complexity medical decision making to assess, manipulate, and support vital systems to treat single or multiple vital organ system failure and/or prevent further life threatening deterioration of the patient s condition? 3. Time requirements met? The critical and unstable nature of the patient s condition should be accurately documented to support the medical necessity of the extended 1 to1 services. 11 Critical Care Services and Time 12

7 Critical Care Time Total Duration of Critical Care Less than 30 minutes Appropriate CPT Codes or or other appropriate E/M code minutes X minutes X 1 and X minutes X 1 and X minutes X 1 and X minutes X 1 and X minutes or longer as appropriate (per the above illustrations 13 Critical Care Services and Time Minimum of 30 minutes to report May be continuous or aggregate, i.e. total duration of time on date of service Report range of time (9:00-9:45) or total time (45 min) Initial critical care time (99291) must be met by single provider. Physicians with same specialty and from same group practice can not report for same patient on same calendar date. 14

8 Critical Care Services and Time Subsequent critical care visits (99292) may represent aggregate time by single physician or physicians within same group practice with same specialty designation, providing medical necessity requirements met. Physicians assigned to critical care unit (hospitalist/intensivist) may not report critical care based on a per shift basis. 15 Critical Care Services and Time Coding critical care services that span the calendar date Example: CC begins at 11:30 pm and continues until 12:15 am the next calendar day. Report for Day 1 Example: CC begins at 11:30 and continues until 12:15am the next calendar day. CC reinitiated at 2:00 am until 3:00 am. Report for Day 1 and for Day 2 16

9 Critical Care Service and Time Caution: Submission of claims for greater than 12 hours of critical care by one provider for one or more patients on same calendar date. Submission of claims from several providers for multiple units of critical care for single patient. 17 Critical Services and Full Attention Activities include evaluating, managing, and providing care to critically ill or injured patient. Full attention: cannot provide services to any other patient. Time must be spent at the patient s bedside or elsewhere on the unit but must be immediately available to the patient. 18

10 Critical Care Services and reportable activities All work related to patient s care that occurs on the floor/unit direct bedside time time spent reviewing test results and/or reviewing old records, discussing case with staff, documenting in the medical record, and time spent with family members or other decision makers when patient is unable to make decision as long as work is directly related to patient s care and management. Time spent off the unit/floor can not be counted (even if related to patient s care). 19 Critical Care Services and reportable activities Time speaking with family can be reported as critical care if: Patient is unable to participate in giving history and/or making treatment decisions Discussion is necessary for determining treatment decisions and the nature of those treatment decisions *Routine daily updates to family do not specifically count towards critical care time Necessity to have the discussion Ex. Due to rapid deterioration, I needed to immediately discuss treatment options with the family Discussions occur while immediately available to patient 20

11 Critical Care Services and Bundled Procedures Do not report separately on day provider bills for Critical Care Services (time spent performing these services may be counted towards critical care) Interpretation of cardiac output measurements (93561, 93562) Chest x-rays, professional component (71010, 71015, 71020) Blood gases, and information data stored in computers (e.g., EKGs, hematologic data-99090) Gastric intubation (43572, 91105) Pulse oximetry (94760, 94761, 94762) Transcutaneous pacing (92953) Ventilator management ( , 94660, 94662) Peripheral vascular access procedures (36000, 36410, 36415, 36591, 36600) 21 Critical Care Services and Unbundled Procedures Time spent performing these procedures is not considered when determining critical care time. Examples of common procedures for critically ill or injured patient which may be separately billed: CPR (92950) Endotracheal intubation (31500) Central line placement (36556) Arterial catheterization (36620) Tube thoracostomy (32551) Temporary transvenous pacemaker (33210, 33211) 22

12 Critical Care Services Documentation Documentation must support: Patient s condition meets the definition of a critical illness or injury, i.e. statement covering the nature of the critical illness or injury. Total critical care time-minimum of 30 minutes. (Key component) Description of all physician s interval assessments of the patient s condition, any acute impairments of organ systems, description of significant lab, imaging, EKG findings, timing and rationale of interventions, and patient response to treatment. Separately reportable procedures not included in the aggregation of critical care time should be clearly delineated. Statement indicating that time spent performing separately reportable procedures was not included in total critical care time. 23 Critical Care Services Documentation Not subject to same requirements that apply to other E/M services (History, Physical Exam, Medical Decision Making). Admission note and/or progress note and documentation of critical care episode should stand apart and be readily identifiable within the medical record. Longer periods of critical care (e.g. >104 minutes) should be supported with interval notes justifying the critical and unstable nature of the patient requiring extended time spent in direct patient care. ** Under review, the severity of the illness itself, the care provided, and the time claimed may all be considered. 24

13 Critical Care Services Documentation Troublesome Critical Care documentation: No acute events overnight NAD Resting comfortably VSS Critical illness/injury ruled out Reasonableness of time statement Medical record documentation of critical care services should demonstrate the patient s condition warranted the type and amount of services provided. 25 Critical Care Services Documentation CC: shot into bullet proof vest HISTORY Comprehensive History obtained from patient & documented PE Primary Survey A-Patent B-Spont C-Intact Secondary Survey normal VS PE WNL (7 Body Areas/Organ Systems) Chest exam-ctab, tender to palpation anterior chest Ext-Decreased sensation RLE, Pain with R hip flexion 26

14 Critical Care Services Documentation Data-CXR, Chest CT, Head CT all normal Case discussed with attending IMPRESSION (attending documentation) GSW to Kevlar vest No apparent injury other than anterior chest wall contusion. May discharge home. Critical care time: 35 minutes 27 Critical Care Services Documentation ICU Day #9 Patient examined and discussed with ICU team. Critical care diagnoses Subacute delirium Bilateral pneumothorax Acute blood loss anemia Hypoxia Severe protein malnutrition No hyperglycemia Plan Pain regimen addressed; OT/PT Right chest tube remains On Supplemental O2 Started on dysphagia diet Family updated. Will transfer to ward. Critical care time: 90 minutes 28

15 Critical Care Services and Multiple Physicians/Providers 29 Multiple Providers of Critical Care Concurrent care as defined by Medicare: When more than one physician (hospitalist, intensivist, surgeon, etc.) renders services more extensive than evaluating and providing an opinion on an aspect of the patient s care during a period of time. 30

16 Multiple Providers of Critical Care CMS-Concurrent critical care services provided by each physician must be medically necessary and not provided during the same instance of time. CPT -Only one physician/provider may report services for a given hour of critical care, even if more than one physician/provider has rendered care to the patient. 31 Multiple Providers of Critical Care May be paid if: Meets critical care criteria Medically necessary Not duplicative Generally of a different specialty Example Cardiologist vs. Pulmonologist 32

17 Multiple Providers of Critical Care Under review, the following will be considered to support concurrent care: Patient s condition and if it warrants services of more than one physician on more than an advisory basis, considering the patient s diagnosis and the physician s specialties/subspecialties addressing different aspects of care. Services can not duplicate one another; each physician must be managing one or more critical illness(es) or injury(ies). Different diagnosis codes help distinguish that care is not overlapping. 33 Critical Care in the ED Patient arrives to ED with crushing chest pain and full cardiac work up performed ED provider provides 35 minutes of critical care and reports Cardiologist called to evaluate and takes over care of patient, provides critical care services, and admits the patient to the CCU Cardiologist may also report

18 Critical Care and other Evaluation and Management on the Same Day Physician saw patient in the morning in the hospital and reported subsequent hospital care. Later in the day, patient becomes acutely ill and critical care services are performed by NPP from same group. Physician reports appropriate E/M under NPI Critical care services reported under NPP s NPI with Modifier Critical Care-Two Physicians of Same Specialty Dr. A-Cardiologist performs 40 minutes critical care in the morning Dr. B-Cardiologist from same group performs 30 minutes of critical care in the evening Report under either physician s NPI, but not both as combined time does not exceed threshold for billing subsequent critical care (74 minutes) 36

19 Critical Care-Two Physicians of Same Specialty Dr. A a pulmonologist performs 45 minutes of critical care Dr. B a cardiologist same practice performs 40 minutes of critical care Dr. A bills a Dr. B could bill a as long as the services are not duplicative 37 NPPs and Critical Care Services A split/shared E/M service performed by a qualified NPP and physician of the same group practice (or employed by the same employer) cannot be reported as a critical care service. May not be reported as combined service or sum of individual times. Critical care services are reflective of care and management of individual physician or qualified NPP for the specified reportable period of time. 38

20 NPPs and Critical Care Services Should be reported under the National Provider Identifier (NPI) of the physician or qualified NPP respectively, when documentation supports code and time requirements. Specific state, hospital, or insurance restrictions may apply to billing of critical care services by NPP. 39 Critical Care Services and Global Period Preoperative critical care may be paid in addition to global fee if Patient is critically ill and requires full attention of physician; and Service is unrelated to specific anatomic injury or general surgical procedure performed Modifier 25 with 99291and/or Postoperative critical care may be paid in addition to global fee if Documentation supports that critical care was unrelated to specific anatomic surgery performed Modifier 24 with and/or Time spent performing the pre, intra and/or post procedure work shall be excluded from the time spent providing critical care. 40

21 Teaching Physicians 41 Critical Care Services: Teaching Physician Teaching physician must be present for the entire period of time for which the claim is submitted. Time spent teaching may not be counted towards critical care time. Teaching physician cannot bill for time spent by the resident providing critical care services in their absence. Only time that the teaching physician spends alone with the patient, or that he/she and the resident spend together with the patient, can be counted 42 toward critical care time.

22 Critical Care Services: Teaching Physician Documentation Teaching physician s documentation may tie into the resident's documentation-may refer to the resident s documentation for specific patient history, physical findings and medical assessment. The teaching physician s stand alone documentation is what determines whether a critical care service(s) can be billed. 43 Critical Care Services: Teaching Physician Documentation CMS requirements: (1) the time the teaching physician spent providing critical care, (2) that the patient was critically ill during the time the teaching physician saw the patient, (3) what made the patient critically ill, and (4) the nature of the treatment and management provided by the teaching physician. Medical review criteria are the same for the teaching physician as for all physicians re: critical care. 44

23 Documentation example 99291: Patient seen and examined with Dr. (Resident). Reviewed and agree with his/her note and the plan of care we developed together. One hour of critical care time personally performed due to patient s hemodynamic instability. Patient was resuscitated with 2 units of packed red blood cells, vasopressor drugs and is currently stable. Teaching physician personally present Acute impairment of vital organ system Treatment(s) initiated Response to treatment Total critical care time 45 Coding example 50 year old female, MVA, brought to ED with tibia fracture and splenic bleed-surgeon consulted: Initially hypotensive but responded to fluid resuscitation Central venous catheter placed due to poor IV access Trauma Surgeon evaluated patient-initial and secondary survey, FAST, CT scan abdomen & pelvis, blood, urine, EKG, lower extremity xray Significant for small tear and blood around spleen, low HCT & tibia fracture Communicated with orthopaedic surgeon, PCP, family while in ED = 90 minutes of direct attendance in ED, exclusive of catheter insertion CPT codes include-99291, 99292(Critical care-ed),

24 Coding example Patient admitted to SICU, Trauma Service with orders for blood transfusion & continued monitoring overnight in ICU. HD 2-no events overnight; remains stable and orthopaedic surgeon plans for ORIF tibia later in the day CPT code-99232, Subsequent hospital care 47 References: Medicare Claims Processing Manual, Chapter 12 (Physicians/Nonphysician Practitioners) Sections & 40-Accessed February Guidance/Guidance/Manuals/Downloads/clm104c12.pdf CMS Transmittal 1548 & MLN Matters: MM5993-Critical Care Visits (Codes ) CMS Global Surgery Billing Guide 2015 Current Procedural Terminology 2016, Professional Edition CPT Assistant, August 2014, July

25 Contact the presenter: Dianne Rodrigue, PA, MHP, CCDS, CPC