Billing For Family Meetings as Critical Care in the ICU Explained.

Can a physician bill family meetings as critical care in the ICU?  This is a situation that happens with daily frequency in ICU medicine.  Hospitalists and intensivists are always meeting with family and other surrogate caregivers for critically ill patients.  Can this resource time spent in family meetings be billed for and paid for based on current evaluation and management (E/M) rules?  That's a question I was recently asked.  Here is the reader's question in detail:
Hello, I have known about your website for a while, but I haven't really investigated it much until recently. I'm a young hospitalist who finished residency several years ago. This past April, I went to this inpatient coding session at an ACP meeting. Their physician did an excellent job and that has been really helpful to me and I have since been spreading it to my group. I am a hospital-employed physician and unfortunately, we have a bare-bones coding department. Thus, I have run into a few situations where my coding person hasn't been able to answer my questions fully. I was hoping to run a situation by you to see how you personally might handle the coding or maybe you know of an easy resource that I can look at to answer the question.

 I need to know what to do in the following situation: I see a ventilated patient. I manage his vasopressors.  I manage his vent.   I assess his critical care needs. It’s all maximal life support and life threatening. I do this at 8AM in the morning. I bill for 60 minutes of critical care. That is the clear part.

What is unclear is later in the day when the family comes in and they request an update. I spend 45 minutes with the family and we discuss his case. We discuss findings, diagnostics, treatment options, etc. The entire time is spent counseling on these topics. How do I bill this subsequent visit? Is it billable? Some of my partners said they bill it critical care (99292), but I’m finding conflicting results on this. I found one source that said to bill critical care for this you have to state the following:
  • Patient cannot participate 
  • Need guidance regarding further care 
  • Need to discuss code status 
  • Explain prognosis 
  • Review other options regarding other care
  • Review other options regarding other care OR stopping care (end of life discussion)
Should I bill a 99292 (extra critical care time)? Can you bill a subsequent visit code (99233) based on the counseling since it’s not critical care. I don't think a prolonged service code can be used if I don't have a subsequent visit code already billed. Thanks so much for your help. If this is too much, I understand. Thanks for your site!
Thanks for your question reader.  Your question has actually been answered by the Centers for Medicare & Medicaid (CMS) directly.   Look for section 30.6.12 titled Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 9 9292) (page 65), under Section E titled Critical Care Services and Physician Time (starting on page 68)  where they discuss family counseling/discussions in Section E starting on page 69.  They give you the answer in this Chapter 12 of the Medicare Claims Processing Manual  on pages 69 and 70.  Here is what they say:

Family Counseling/Discussions:
  • Critical care CPT codes 99291 and 99292 include pre and post service work. Routine daily updates or reports to family members and or surrogates are considered part of this service. However, time involved with family members or other surrogate decision makers, whether to obtain a history or to discuss treatment options (as described in CPT), may be counted toward critical care time when these specific criteria are met:
    • The patient is unable or incompetent to participate in giving a history and/or making treatment decisions, and 
    • The discussion is necessary for determining treatment decisions.
  • For family discussions, the physician should document the following
    • The patient is unable or incompetent to participate in giving history and/or making treatment decisions.
    • The necessity to have the discussion (e.g., "no other source was available to obtain a history" or "because the patient was deteriorating so rapidly I needed to immediately discuss treatment options with the family"), 
    • Medically necessary treatment decisions for which the discussion was needed, and 
    • A summary in the medical record that supports the medical necessity of the discussion.
  • All other family discussions, no matter how lengthy, may not be additionally counted towards critical care. Telephone calls to family members and or surrogate decision-makers may be counted towards critical care time, but only if they meet the same criteria as described in the aforementioned paragraph. 
So the answer to your question is yes.  Talking with family in a family conference can be billed as critical care if the criteria detailed above are followed.   If your family conference time meets the  criteria detailed above and your additional time spent passes beyond the 74 minute threshold for critical care code 99291, then bill for a 99292 for each additional 30 minutes of time spent beyond 74 minutes of initial calendar date 99291 critical care time.  What if one physician provides the time for 99291 and another physician provides the family visit that qualifies for an add-on code 99292?  Is that allowed?  In this same resource detailed above in Section E (page 68) Medicare says, " Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician (§30.6.5)."  In the past, Medicare computers could not handle having different physicians provide a 99291 and a 99292.  They should, because they say they should.  Perhaps they have finally fixed their algorithms to follow their own policy.You can find much more about CPT coding by obtaining your own copy of the AMA's 2013 CPT manual available at the graphic above and to the right.

In answering your additional questions, you cannot bill a subsequent care code after a critical care code on any given calendar date, but you can bill critical care after and E/M code.  I have previously discussed this and have detailed when it is appropriate to bill an E/M charge and a critical care code on the same date at the provided link.    In addition, you cannot bill a prolonged care add-on code with critical care.  I have previously discussed add-on codes  99356 and 99357 in the hospital setting.  Only certain E/M codes are allowed to be companion codes with these prolonged care codes .  Critical care codes are not included as acceptable companion codes.  I hope this helps.

The Happy Hospitalist has a wealth of other coding information for all your clinical needs.  You can find all my CPT and E/M coding lectures here.  I also have an assortment of clinical relevant information in my hospitalist resources section as well and a bedside E/M bedside pocket reference card detailed below. 


LINK TO HOSPITALIST E/M POCKET REFERENCE CARD POST


EM Pocket Reference Cards Using Marshfield Clinic Point Audit



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