Coding and Billing E&M and Critical Care Services in 2022

The Centers for Medicare and Medicaid Services (CMS) has finalized the Physician Fee Schedule (PFS) Rules for CY2022.  A multitude of payment policy changes are implemented to promote telehealth services, enhance diabetes prevention programs, and further incentivize quality payment programs.  Refinements are also made to code sets involving Evaluation and Management (E&M), Critical Care, and Split/Shared Services.  Listed below are the latest guidelines and examples for billing Critical Care Services; Critical Care and E&M on Same Day; Split Shared and E&M Visits; Split Shared and Critical Care Visits; as well as Observations/Inpatient and Prolonged Services. 

ED Visit followed by Critical Care 

It is now acceptable to have an ED visit and same day critical care if the non-critical visit happens first.  The physician should document that the patient did not initially meet critical care services criteria and later became critical and required interventions. 

Example 

• The patient presents with chest pain, given ASA, has appropriate work up with normal EKG and troponin, but has multiple risk factors, so was observed for serial troponins to evaluate for acute ischemia.  Assuming all elements are documented completely and comprehensive history and physical is done – this would qualify as a 99285.

• Two hours later, while awaiting a second troponin, the patient develops worsening chest pain.  EKG repeated and now shows deep ST depression.  The patient is hypertensive and tachycardic, treated with IV Lopressor and Heparin.  Cardiology consulted and the patient is admitted to ICU.  The physician documents a good critical care note with 35 minutes of critical care explaining that the patient was initially felt to be high risk, but did not meet critical care criteria, then later developed organ system dysfunction – the patient qualifies for a 99291. 

• The total of the two visits would be 99285-25 + 99291 

Critical Care Split Shared Services - What’s New (1) 

When splitting critical care between a physician and either a PA or APN: 

• Critical care time cannot be shared across different provider levels 
• Each provider type must record their time spent in minutes and the sum of their times must exceed the threshold of 30 minutes 
• Minimum 75 minutes to bill for both provider types 

Example 1: 

• APN sees patient first for 25 minutes 
• Physician sees patient for 10 minutes 
• Total time is 35 minutes  
• Billable as critical care under the APN as both together did meet the minimum 30-minute threshold for critical care time 

Example 2: 

• PA sees patient for 35 minutes 
• Physician sees patient for 40 minutes 
• Total time is 75 minutes, so can be billed 99291 to physician and billed 99292 to PA 

Example 3: 

• PA sees patient for 50 minutes 
• Physician sees patient for 25 minutes 
• Total time is 75 minutes, billed 99291 to PA and since PA performed the substantive portion of the second hour (25 of the 30 minutes), can bill 99292 to the PA 

Critical Care Concurrent Care 

• Two or more clinicians can provide critical care the same day regardless of specialty 
• If same specialty, the first clinician should bill 99291 and can sum the time of same category of providers with simultaneous time or different level providers for serial time to meet the minimum 
• After 75 minutes of critical care between the two or more clinicians, can bill 99292 
• Time spent concurrently can be counted when medically necessary 
• If different specialties, each can simultaneously bill 99291 

Critical Care Split Shared Services - What’s New (2) 

When sharing a visit between a physician and either a PA or APN: 

• Can bill under the physician if the physician performs the “substantive portion” of either the history, physical, MDM, or time of the visit 
• One provider must have a face-to-face visit  
• There is no longer a face-to-face requirement for both providers 
• Can bill under the physician if they perform the substantive portion (>50%) of the MDM 

Physician should only state they performed the substantive portion of the visit if they did indeed perform >50% of at least one of the key elements of the visit (history, physical, MDM, time)

Split Shared Services for ED, HM Visits 

Example 1: 

• APN sees patient, performs and documents H&P and MDM 
• Physician and APN discuss the case and physician guides the work up and reviews labs, imaging, and prior notes.  Physician feels he/she did the substantive portion of the MDM, so documents physician performed the substantive portion of the MDM 
• Visit billable under the physician since he/she performed the substantive portion of the MDM 

Example 2: 

• PA sees patient; performs and documents H&P and MDM 
• Physician sees patient repeating the entire exam, they discuss MDM and physician guides the care and documents their exam or agrees with the PAs exam as documented 
• Visit billable under the physician since he/she performed the substantive portion of the exam (entire exam) 
• Can bill under the physician if he/she performs the substantive portion (>50%) of the visit 

Example 3: 

• PA sees patient; performs and documents H&P and MDM, notes he/she discussed the case with the physician 
• Physician says that sounds like a good plan and signs the chart 
• Bill under the PA as the physician does not state he/she performed the substantive portion 

Example 4: 

• APN sees patient; performs and documents H&P and MDM, is unsure of the X-ray findings, so asks physician to look at the films which the physician does, makes a diagnosis, and dictates the treatment plan to the APN 
• Physician documents he/she performed the substantive portion of the MDM
• Visit billable under the physician since he/she performed the substantive portion of the MDM 

Example 5: 

• Physician sees patient with significant head injury, performs and documents H&P and MDM  
• PA repairs the scalp laceration 
• Visit billable under the physician since he/she performed the substantive portion of the visit 
• Procedure billed under the PA 

Split Shared Services for Procedures 

Procedures cannot be split shared.  They can be performed together with assistance from another provider type 

Example 1 

• PA performs laceration repair 
• Physician watches for a bit to see if the procedure is performed correctly
• Bill under the PA
• Supervision for billing can be performed by attending supervising residents, but not PAs/APNs 

Example 2 

• Patient with shoulder dislocation 
• Physician reduces shoulder with APN’s assistance 
• Bill under the physician 

Observations/Inpatient and Prolonged Services 

• For Observations and Inpatient visits, can use time as well   
• When including a prolonged services code on the same date of service as an initial visit, must sum up the total time and whoever performs the majority of the time gets the credit for both initial visit and prolonged services 

Example 1 

• Patient in observation, seen by PA at 0900, documents 35 minutes of Observations care 
• Later, patient has a seizure that spontaneously resolves, seen by attending for 30 minutes
• Both 99226 subsequent Observations visit and 99356 Prolonged services visit billed under the PA because the PA performed >50% of the visit 

Example 2 

• Patient in Observation, seen by PA at 2200 
• Physician consulted by PA at 2300 and case discussed. Physician guides the plan and documents he/she performed the substantive portion of the MDM 
• Physician does not see patient until next morning 
• Can bill both visits under physician as the physician performed the substantive portion of MDM on yesterday’s visit and an entire visit today 

Potential Attestations (Minimum Documentation for Billing Assignment) 

Example 1 

• I, Dr. Smith, performed the substantive portion of the MDM on date at time.  Signed and dated 

Example 2 

• PA documents: The physician, Dr. Smith, performed the substantive portion of the MDM.  
• Physician signs, date and time 

Example 3 (Physician did have a face-to-face visit) 

• I saw and evaluated the patient and performed the substantive portion of the MDM.  I agree with the findings as noted by the APN 
• Signed timed and dated by physician 

How Reventics Helps 

New rules, policy refinements, and quality incentives in PFS CY2022 necessitate comprehensive documentation of all services furnished to maximize compliant revenue.  Reventics uses a clinically focused and analytics-led approach to deliver provider engagement solutions improving physician reimbursement and compliance while elevating clinical quality measures performance.  Connect with us at to start your journey to better engagement, optimized revenues, and improved compliance.