Current through Register Vol. 43, No. 02, November 27, 2024
(1) When caring
for a critically ill patient in which the constant attention of the physician
is required, the appropriate critical care procedure code must be billed. Refer
to the CPT and the Alabama Medicaid Provider Manual for additional guidance and
clarification.
(2) The actual time
period, per day, spent in attendance at the patient's bedside, or performing
duties specifically related to that patient, irrespective of breaks in
attendance, must be documented in the patient's medical record.
(3) Only the following individual procedures
related to critical care may be billed:
(a)
Procedure code 99360 (stand by) and either procedure code 99221, 99222, or
99223 (initial hospital care) may be billed once with each hospital
stay.
(b) An EPSDT screening may be
billed in lieu of the initial hospital care (Procedure code 99221, 99222, or
99223).
(c) Procedure code 99082
(transportation/escort of patient) may be billed only by the attending
physician. Residents or nurses who escort a patient may not bill either
service.
(4) Pediatric
and Neonatal Critical Care. The purpose of the following policy statements is
to provide assistance to providers seeking to bill procedures for critical
care. Refer to the CPT and the Alabama Medicaid Provider Manual for additional
guidance and clarification.
(a) Pediatric and
neonatal critical care codes begin with the day of admission and may be billed
once per patient, per day, in the same facility.
(b) The pediatric and neonatal critical care
codes include management, monitoring and treatment of the patient, including
respiratory, pharmacological control of the circulatory system, enteral and
parenteral nutrition, metabolic and hematologic maintenance, parent/family
counseling, case management services and personal direct supervision of the
health care team in the performance of their daily activities.
(c) Once the patient is no longer considered
by the attending physician to be critical, the Subsequent Hospital Care codes
should be billed.
(d) Refer to the
Alabama Medicaid Provider Manual for guidelines on what additional procedures
may be billed in conjunction with critical care. General guidelines are:
1. Initial history and physical or EPSDT
screen may be billed in conjunction with 99293 or 99295. Both may not be
billed. One EPSDT screen for the hospitalization will encompass all diagnoses
identified during the hospital stay for referral purposes.
2. Standby (99360) or resuscitation (99465)
at delivery or attendance at delivery (99464) may be billed in addition to
critical care. Only one of the codes may be billed in addition to critical
care.
3. Subsequent Hospital Care
codes (99231-99233) may not be billed.
4. Critical care is considered to be an
evaluation and management service. Although usually furnished in a critical or
intensive care unit, critical care may be provided in any inpatient health care
setting. Services provided which do not meet critical care criteria should be
billed under the appropriate hospital care codes. If a recipient is readmitted
to the NICU/ICU, the provider must be the primary physician in order for
NICU/ICU critical care codes to be billed again.
5. Transfers to the pediatric unit from the
NICU cannot be billed using neonatal critical care codes.
6. Global payments encompass all care and
procedures which are included in the rate. Physicians may not perform an EPSDT
screen and refer to partner or other physician to do procedures. All procedures
which are included in the daily critical care rate, regardless of who performed
them, are included in the global critical care code.
7. Consultant care rendered to children for
which the provider is not the primary attending physician must be billed using
consultation codes. Appropriate procedures may be billed in addition to
consultations. If, after the consultation the provider assumes total
responsibility for care, critical care may be billed using the appropriate
critical care codes as defined in the Alabama Medicaid Provider Manual. The
medical record must clearly indicate that the provider is assuming total
responsibility for care of the patient and is the primary attending physician
for the patient. Consultation and critical care cannot be billed on the same
patient on the same day.
(5) Intensive (Non-Critical) Low Birthweight
Services.
The purpose of the following policy statement is to provide
assistance to neonatology providers seeking to bill for intensive
(non-critical) low birthweight services. Refer to the CPT and the Alabama
Medicaid Provider Manual for additional guidelines and clarification. Intensive
(non-critical) low birthweight services codes are used to report care
subsequent to the day of admission provided by a neonatologist directing the
continuing intensive care of the very low birthweight infant who no longer
meets the definition of being critically ill. Low birthweight services are
reported for neonates less than 2500 grams who do not meet the definition of
critical care but continue to require intensive observation and frequent
services and intervention only available in an intensive care
setting.
Author: Desiree Nelson; Program Manager; Medical
Support
Statutory Authority: Title XIX, Social Security
Act; 42 C.F.R. §
440.50; CPTl4.
