Prepayment edit of evaluation and management (E/M) code 99291

Recent data analysis pertaining to critical care services has identified that First Coast Service Options (First Coast) is at a high risk for claim payment error. The error is based on potential overutilization and/or abuse of code 99291, which is defined in the Current Procedural Terminology (CPT ®) manual as follows:

• Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.

• Critical care is defined as the direct delivery by a physician(s) 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.

• 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. Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present.

Providing medical care to a critically ill, injured, or post-operative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements.

Critical care services must be medically necessary and reasonable. Services provided that do not meet the requirements for critical care services or services provided for a patient who is not critically ill or injured in accordance with the above definitions and criteria but who happens to be in a critical care, intensive care, or other specialized care unit should be reported using another appropriate evaluation and management (E/M) code (e.g., subsequent hospital care, CPT ® codes 99231 – 99233).

Critical care is usually, but not always, given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit, or the emergency department. However, payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care.

Critical care is a time-based service, and for each date and encounter entry, the physician’s progress note(s) shall document the total time that critical care services were provided. The duration of critical care services to be reported is the time the physician spent evaluating, providing care and managing the critically ill or injured patient’s care. That time must be spent at the immediate bedside or elsewhere on the floor or unit so long as the physician is immediately available to the patient. For any given period of time spent providing critical care services, the physician must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.

The CPT ® critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous. Non-continuous time for medically necessary critical care services may be aggregated. Reporting CPT ® code 99291 is a prerequisite to reporting CPT ® code 99292. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician.

Based on a potential misunderstanding and/or misapplication of the requirements for providing critical care services, data indicates that providers may be billing for critical care based on the location of service rather than according to the patient’s condition.

In response to the high risk for payment error, First Coast has implemented two prepayment review edits for claims submitted on or after February 18, 2013, which apply to all providers within First Coast’s Florida jurisdiction. Below are summaries of how these edits will be applied:

• A 100% prepayment review edit will be applied to critical care services provided outside the following places of service: 21 Hospital, 22 Outpatient Hospital, 23 Emergency Room.

• A prepayment edit will be applied to all utilization outlier claims identified.