How to aggregate physician time to bill E/M services
By Brett Baker
Q: Can I aggregate the time I spend on critical care with another physician in my group? All payment goes to the group, not individual physicians.
A: While the Centers for Medicare and Medicaid Services (CMS) currently has no national policy addressing your question, it is in the process of implementing a policy that would address it.
Under that policy, a single physician must provide critical care services to bill CPT code 99291, which covers 30 to 74 minutes of patient care. Therefore, aggregating time among physicians in the same group for CPT code 99291 is not allowed.
You may, however, combine the time you spend on critical care activities beyond 30 to 74 minutes with the time spent by another member of your group to meet the time requirements for billing 99292. That code requires at least 75 minutes of patient care activities. (See the table in the introductory text to the critical care codes found in the CPT book for guidance on billing 99292.)
A split/shared E/M service between a physician and a nonphysician practitioner is not allowed as critical care. (See "Medicare issues new rules to bill for shared services" from the December 2002 ACP Observer.)
While the CMS has not yet implemented this policy, your Medicare carrier may have its own policy, known as a local coverage decision, on how physicians in the same group can bill for critical care services. Carriers can follow their own policies until the CMS implements a national policy.
You should follow the policy that the CMS plans to implement unless your carrier has a local policy. Carriers' local policies can't conflict with CMS policies.
You can check to find out if your carrier has a local policy relating to critical care through the CMS Web site or check with your carrier.
ACP will publish more about the CMS' national policy once it is finalized.
Critical care and subsequent hospital care
Q: Suppose I meet the criteria for billing CPT code 99291, but the combined time spent by myself and a colleague does not meet the threshold for billing 99292. Can my colleague bill for a subsequent hospital visit on the same day I bill a critical care service?
A: Yes. A second physician in a group can bill for a subsequent hospital visit provided to the same patient on the same date the first physician in the group billed for a critical care service using 99291. CMS policy states that medically necessary visits that do not meet critical care requirements may be billed by a physician in the same group practice on the same date that another physician in the group bills for a critical care service.
Prolonged services with direct (face-to-face) contact
Q: Can I bill for an E/M service and a prolonged service add-on code by aggregating the time my colleagues and I spend providing the service?
A: Yes. Medically necessary prolonged service with direct (face-to-face) patient contact can be reported when the total duration of physician face-to-face service equals or exceeds the threshold time for the relevant E/M service code. See "Adding prolonged service codes," this page.
"Face-to-face" is defined as the actual time you spend with the patient in the office and other outpatient settings. In inpatient settings, this is defined as "floor/unit" time. (To determine if it is appropriate to add a prolonged service code, consult the "typical times" assigned to E/M service codes in the CPT code book.)
Q: What's an example of an instance in which two physicians in the same group each may provide an E/M service to a patient on the same date and aggregate their time to warrant a prolonged service code?
A: A hospitalized patient who does not quite meet the criteria for critical care provides an example of when two different physicians from the same group may furnish services to the same patient for the same problem over the course of the same date.
The two physicians' combined initial inpatient service totals two hours (120 minutes) of face-to-face patient contact. Physicians in the same group practice may bill as if they were a single physician.
Under this scenario, the group would bill CPT code 99223, the highest initial inpatient service code with a typical time of 70 minutes. The group would also bill CPT code 99356, first hour of prolonged service with direct (face-to-face) contact to an inpatient. (See the introductory text to the prolonged service codes in the CPT code book for guidance.)
Teaching physician rules and documentation requirements
Q: Can attending physicians select a level of service for a hospital discharge by aggregating the time they have spent with a resident providing discharge services to a patient? With Medicare rules requiring that the teaching physician must personally furnish or be present for the "key portion" of the service, what constitutes the "key portion" for time-based E/M services involving residents?
A: Medicare defines the "key portion" of a service as "the portion of the service that determines the level of service billed" for E/M services. Medicare rules state that a teaching physician must be present for the entire amount of time used to determine the level of service billed for time-based codes. The teaching physician's time includes the time he or she spends alone with the beneficiary or performing the service, as well as the time he or she and the resident spend with the beneficiary or performing the service. The teaching physician cannot include the time the resident alone (in the absence of the teaching physician) spent with the beneficiary or performing the service.
These rules pertain specifically to the following time-based E/M services:
- critical care services (CPT codes 99291 to 99292);
- hospital discharge day management (CPT codes 99238 to 99239);
- E/M codes in which counseling and/or coordination of care dominates the encounter (accounting for more than 50% of the time spent), and time is considered the key or controlling factor to qualify for a particular level of E/M service;
- prolonged services (CPT codes 99358 to 99359), and
- care plan oversight services (HCPCS codes G0181 to G0182).
Brett Baker is a third-party specialist in the College's Washington office.
You can use the prolonged service codes as an add-on to the following E/M service codes:
Office or outpatient setting, CPT codes 99354 through 99355:
- new and established patient office visits;
- office consultations; and
- new and established patient home services.
Inpatient setting, CPT codes 99356 through 99357
- initial and subsequent hospital care;
- initial and follow-up inpatient consultations;
- comprehensive nursing facility assessments; and
- subsequent nursing facility care.
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