Critical Care Coding 2023

[thegenius]

Is anyone aware whether the critical care time brackets have changed for 2023? I read this

CPT® and CMS Rules for Critical Care | What's the Difference?

CMS issued a “technical correction” in the 2023 PFS Final Rule. Here's what they said about code 99292 and critical care time

codingintel.com

and made me wonder. Is it just for Medicare patients or are all patients subject to this?

First I've heard of it.

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[gutonc]

Is anyone aware whether the critical care time brackets have changed for 2023? I read this

CPT® and CMS Rules for Critical Care | What's the Difference?

CMS issued a “technical correction” in the 2023 PFS Final Rule. Here's what they said about code 99292 and critical care time

codingintel.com

and made me wonder. Is it just for Medicare patients or are all patients subject to this?

First I've heard of it.

i can't answer your first question, but for your second question, the answer is yes. CMS defines the codes and everyone uses them. Doesn't matter who's paying the bill.

 

[Tenk]

I’ll just stick to always documenting 42 minutes of critical care time.

 

[USCDiver]

I saw a talk from one of the executives from our billing company last week. Currently CMS has this new rule that has not yet been adopted by private payers.

 

[Mount Asclepius]

Is anyone aware whether the critical care time brackets have changed for 2023? I read this

CPT® and CMS Rules for Critical Care | What's the Difference?

CMS issued a “technical correction” in the 2023 PFS Final Rule. Here's what they said about code 99292 and critical care time

codingintel.com

Yes, our coders started billing based upon the new times as of 1/1/23.

I would suspect there will be a lot of random times in the 30s and 100s now instead of the 30s and 70s.

 

[thegenius]

Freaking sucks. Hate it. And @Mount Asclepius I agree now just more random numbers between 30-104.

 

[FlaminHotER]

Just keep piling on the Bull sh t onto our plates

 

[BoardingDoc]

Is anyone aware whether the critical care time brackets have changed for 2023? I read this

CPT® and CMS Rules for Critical Care | What's the Difference?

CMS issued a “technical correction” in the 2023 PFS Final Rule. Here's what they said about code 99292 and critical care time

codingintel.com

and made me wonder. Is it just for Medicare patients or are all patients subject to this?

First I've heard of it.

Just medicare currently. The upside is that time is additive with a mid-level right now as well. If you happen to be working with a pa, just have them bill 60 and you do 50. Otherwise, yeah, I see very few cases where I'm justifying 105 minutes.

 

[southerndoc]

I rarely - if ever - bill for more than 60 mins of critical care time. However, I'm at a tertiary center. I bet that rural hospitals that keep people for a while before shipping them out (waiting on EMS or an accepting facility) bill a ton of this. It will definitely affect their billing.

 

[gro2001]

I have a smart phrase that use for critical care time. It looks something like:

I personally provided XX minutes of critical care time, exclusive of procedures.
-reviewing images X
-reviewing labs X
-examining patient X
-formulating plan X
-updating patient/family at bedside X
-discussing with consultants/admitting team X
-adjusting ventilator X
-titrating drips X
-documenting X

I replace X with a number of approximately how many minutes I spend on each one (most things get 5 if they are relevant; if there is no imaging or no drips or whatever I just take out the line; each consultant/team I talk to over the course of the case I add 5 minutes; each cross sectional image I look at I add 5 minutes). Then I add all of them up and write than in place of XX. For most cases it ends up being 35-75 minutes, unless I end up doing a long family meeting or an unusually long code (in which case I add a line about directing CPR)).

This has two advantages:

1) I feel it more solidly backs up my critical care billing because it makes it clear the number isn't random
2) Sometimes it makes me realize that I should bill an additional 30 minutes of critical care time

 

[Siggy]

Just medicare currently. The upside is that time is additive with a mid-level right now as well. If you happen to be working with a pa, just have them bill 60 and you do 50. Otherwise, yeah, I see very few cases where I'm justifying 105 minutes.

On one hand, this will bill under the PLP.

On the other hand a 91 and 92 under the PLP is still worth more than a physician 91 alone.

 

[BoardingDoc]

On one hand, this will bill under the PLP.

On the other hand a 91 and 92 under the PLP is still worth more than a physician 91 alone.

That is not my understanding. If CMS ever implements the whole "whoever spends more time with the patient determines the level of billing (MD vs midlevel)" then that would be correct. That system is not in place and this scenario would bill under the doc at 100%.

 

[EctopicFetus]

I literally recall 1 case in the last 2 years I billed over 74 mins of CC. My group which does 200k+ visits had i think under 10 99292s billed. Our overall CC is in the 7% range. This is a nothing burger.

Also as an FYI CMS and CPT do not agree on some of the details of billing CC. Most of us have only been taught the more stringent criteria which is CMS’

 

[Mount Asclepius]

I literally recall 1 case in the last 2 years I billed over 74 mins of CC. My group which does 200k+ visits had i think under 10 99292s billed. Our overall CC is in the 7% range. This is a nothing burger.

Depends on your environment. Also possibly underbilling 99292. Our group's annual volume is less than yours . Our overall CC billing is also around 7%, but about 0.5% is 99292 with a variable group volume that can exceed 30/month.

Not a nothing burger. It's a way to try to cut CC reimbursement to physicians.

Trying to increase level 3/4's to 4/5's codes has more of an effect though on your compensation than making sure you are accurately billing 99292 given the sheer volume of non-CC patients.

 

[BoardingDoc]

Trying to increase level 3/4's to 4/5's codes has more of an effect though on your compensation than making sure you are accurately billing 99292 given the sheer volume of non-CC patients.

I don't have data yet (should from our coders soon) but I'm cautiously optimistic about these new coding rules. I think it makes getting a 5 harder in many cases than previously, but makes going from a 3-->4 very easy. I currently produce a rather large number of lvl 3 charts as I tend to work people up much less than my colleagues. I'm hopeful that a lot of these 3s are going to become 4s via my new meticulous review of their records/getting hx from EMS/whatever, and giving them an Rx for something like zofran.

 

[Mount Asclepius]

I don't have data yet (should from our coders soon) but I'm cautiously optimistic about these new coding rules. I think it makes getting a 5 harder in many cases than previously, but makes going from a 3-->4 very easy. I currently produce a rather large number of lvl 3 charts as I tend to work people up much less than my colleagues. I'm hopeful that a lot of these 3s are going to become 4s via my new meticulous review of their records/getting hx from EMS/whatever, and giving them an Rx for something like zofran.

Our percentage of level 4/5s increased and level 3 decreased with the change year-to-date. We aggressively prepared for though as a group in 11-12/2022. Also cautiously optimistic.

 

[Siggy]

That is not my understanding. If CMS ever implements the whole "whoever spends more time with the patient determines the level of billing (MD vs midlevel)" then that would be correct. That system is not in place and this scenario would bill under the doc at 100%.

My understanding is that this was supposed to be started last year, but they went with either time or substantial amount of a category option. However this year was supposed to be time only.

Of note… my company’s (straight CCM group) billing agency is terrible.

1. It wasn’t until June or July that they officially rolled out split/share billing (I was started trying to split/share in January based on info from SCCM).

2. They just told us this month about the change in -92 criteria… despite me emailing them months ago based off of a conversation either here or on Reddit.

3. They’re putting subtle pressure on the NPs to bill like 45-60 minutes per patient per day minimum. Most of the physicians have said, “We don’t want to tell the NPs how much time to bill and we’re not going to bill over 12 hours of time in a shift.” If I’m seeing 20 patients, I’m not billing more than 35 minutes per patient.

 

[BoardingDoc]

My understanding is that this was supposed to be started last year, but they went with either time or substantial amount of a category option. However this year was supposed to be time only.

Of note… my company’s (straight CCM group) billing agency is terrible.

1. It wasn’t until June or July that they officially rolled out split/share billing (I was started trying to split/share in January based on info from SCCM).

2. They just told us this month about the change in -92 criteria… despite me emailing them months ago based off of a conversation either here or on Reddit.

3. They’re putting subtle pressure on the NPs to bill like 45-60 minutes per patient per day minimum. Most of the physicians have said, “We don’t want to tell the NPs how much time to bill and we’re not going to bill over 12 hours of time in a shift.” If I’m seeing 20 patients, I’m not billing more than 35 minutes per patient.

The straight CCM thing makes sense for time used. Noone in the ER is using that. They're using the 3 column approach.

And yes, they were thinking about making the bill under the doc only if the doc spent more time than the midlevel, but they stuck with billing under either based on who did the "substantive part of the encounter" which in this case is MD always as we're the one signing the chart and ultimately (in theory) doing the medical decision making.

In the future, your comment about CC getting billed at 85% under the PA if they do 60min and I do 50 might be correct. Not today though.