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Hospital Visits and Critical Care on a same day


Physicians and qualified NPPs should note the payment policy requirements for CPT codes 99221 - 99239 when submitted with Critical care CPT codes 99291 - 99292

When a hospital inpatient or office/outpatient evaluation and management (E/M) service is furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care, both the critical care services (Current Procedural Terminology (CPT) codes 99291 and 99292) and the previous E/M service may be paid for the same date of service. (Note that hospital emergency department services are not paid for the same date as critical care services when provided by the same physician to the same patient.)

During critical care management of a patient those services that do not meet the level of critical care should be reported using an inpatient hospital care service with CPT Subsequent Hospital Care using a CPT code in the 99231-99233 range.

Physicians and qualified NPPs may report both critical care services and an inpatient hospital care service for the same patient on the same calendar date when during critical care management of a patient the services do not meet the level of critical care services.

Physicians and qualified NPPs are reminded that both Initial Hospital Care codes (CPT codes 99221-99223) and Subsequent Hospital Care codes are “per diem” services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.

Physicians and qualified NPPs are advised to retain documentation for discretionary Medicare carrier or A/B MAC review in case claims are questioned. The retained documentation must support why the same physician or physicians of the same specialty in a group practice submitted claims for both critical care services and other E/M services for the patient on the same date of service.

Reference: http://cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM5792.pdf

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