Billing and Documentation

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  • 1.  Global period post-op critical care

    Posted 12-21-2021 11:56
    Edited by Tyler VanDyck 12-21-2021 12:20

    After the webinar earlier in the month, I still felt a little confused as to the implication of the new rule language on post-op critical care.

    Preoperative and/or postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the full attention of the physician, and the critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed (for example, trauma, burn cases). We are creating a new modifier that we will require on such claims to identify that the critical care is unrelated to the procedure. If care is fully transferred from the surgeon to an intensivist (and the critical care is unrelated), modifiers –54 (surgical care only) and –55 (postoperative management only) must also be reported to indicate the transfer of care. The surgeon will report modifier –54. The intensivist accepting the transfer of care will report both modifiers –55 and the new unrelated modifier.

    In review of past releases of CMS rules, it seems the language surrounding critical care only being allowable when "unrelated" to the procedure has existed for years, with the only new change being the addition of the modifiers to identify those claims.  Given the language hasn't changed, I wonder whether it is truly their intention or not limit post-op billing. 

    How exactly are we to interpret "unrelated" as it comes to post-op care?  In one line of thinking, pretty much all post-op critical care could be said to be related to the procedure. For a post op cardiac case, the argument might me made that the mechanical ventilation management, hemodynamic management, etc. is all related to the cardiac surgical procedure.  No surgery to vasoplegia, no need for the vent, etc.  In the extremes of cases with severe post-cardiotomy shock, this has the potential to negate several days of post-op critical care and certainly seems to threaten routine post-op care.  But, it doesn't seem like this line of thinking has been followed in previous renditions of CMS rules. 

    Where does the line get drawn on "unrelated" to allow Critical Care Medicine to bill on a post-op patient?  My institution has released some guidance that threatens our ability to bill for postop critical care and I'm very curious how other shops are going to handle this, or if we need to seek additional clarification from CMS.

    Tyler VanDyck
    Attending Physician
    Allegheny General Hospital
    Pittsburgh PA

  • 2.  RE: Global period post-op critical care

    Posted 12-22-2021 12:42
    In my personal opinion, care provided by us(critical care physicians) distinct from any surgical management is appropriate to be billed as long as documentation also meets the criteria for critical care.Based on the new CMS rules,I do not see any change in practice related specifically to this issue and don't see the need to change billing practices.
    This is a good topic for the the upcoming KEG meeting being planned around Congress time.Will release the date and times soon once scheduled.

    Disclaimer: All opinions expressed are mine and don't reflect any institutional views including SCCM.


    Piyush Mathur
    The Cleveland Clinic
    Cleveland OH