Billing and Documentation

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  • 1.  Bundling of central venous lines and arterial lines

    Posted 11-16-2021 07:54
    Good morning,

    Thank you for your work on this topic.  The changes are very positive for the actual practice of critical care medicine.

    In reading through the CMS document on proposed changes to 99291 and 99292 (pages 451 and 452) the excerpt below which makes it unclear to me whether vascular access procedures now MUST be billed as part of critical care time OR whether the time to perform them must simply be excluded from critical care services: 

    "We proposed to adopt CPT's listing of bundled services that are part of critical care visits: interpretation of cardiac output
    measurements (CPT codes 93561, 93562), chest X rays (CPT codes 71045, 71046), pulse
    oximetry (CPT codes 94760, 94761, 94762), blood gases, and collection and interpretation of
    physiologic data (for example, ECGs, blood pressures, hematologic data); gastric intubation
    (CPT codes 43752, 43753); temporary transcutaneous pacing (CPT code 92953); ventilator
    management (CPT codes 94002-94004, 94660, 94662); and vascular access procedures. As a
    result, these codes would not be separately billable by a practitioner during the time-period when
    the practitioner is providing critical care for a given patient. We also proposed to adopt the CPT
    prefatory language stating that time spent performing separately reportable procedures or
    services should be reported separately and should not be included in the time reported as critical
    care time. "

    In CMS response to comments they state:
    "We note that we included vascular access procedures in the list of bundled services
    because page 31 of the CPT Codebook states that vascular access procedures are included in
    critical care bundle when performed during the critical period by the physician(s) providing
    clinical care. Therefore, we are finalizing as proposed the CPT listing of services bundled into
    critical care. We will review and consider any future changes made by CPT to the listing of
    bundled services, if future changes are made by the CPT Editorial Panel.
    After consideration of public comments, we are finalizing our proposal to adopt the CPT
    definition of critical care services and the current CPT listing of bundled services."

    Does anyone from the group know if CMS will continue to allow separate billing of these procedures if the time used to perform these procedures is not counted toward critical care time?  Are we now mandated to bill all vascular access procedures as part of our critical care time?

    Thank you for your work here.

    Sean Josephs, MD, FCCM

    Sean Josephs
    University of Cincinnati College of Medicine
    Cincinnati OH

  • 2.  RE: Bundling of central venous lines and arterial lines

    Posted 11-16-2021 08:03

    As originally proposed, due to the language used, the concern was that bundling included central line insertions such as those in the CPT 36555-36571 family. The clarification referred back to the AMA CPT guidelines for bundled procedures which include:
    Vascular access procedures (36000, 36410, 36415, 36594, 36600). 

    So Central lines such as 36556 (non tunneled CVL patient > 5 years age) would be billed separately. 
    However, if you place and IV in a critically ill patient (CPT 36000), then you would include the time for the IV placement in your critical care time since the time is bundled.

    Ultimately there is no change in practice from the current practice for vascular access. 

    David Carpenter
    Emory University Hospital
    Atlanta GA