Critical care services are benefits of the CSHCN

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Critical care services are benefits of the CSHCN Services Program. Critical care is the
care of a critically ill client who requires the constant attention of a physician. Critical
care involves highly complex decision-making to access, manipulate, and support vital
system functions. If the physician is not at the client’s bedside, the physician must be
immediately available to the client. The physician must devote his or her full attention to
the client and, therefore, cannot render evaluation and management services to any
other client during the same period of time. Critical care is usually provided in a critical
care area such as a coronary care unit, a respiratory care unit, an intensive care unit, a
pediatric intensive care unit, a neonatal intensive care unit, or an emergency department
care facility.
Noncritical intensive care is a benefit for those infants that are low birth weight (LBW) or
very low birth weight (VLBW) when they no longer meet the definition of “critically ill” but
continue to require intensive observation and frequent services and interventions that
are only available in the intensive care setting. Newborn resuscitation may be a benefit
for high risk newborns that require resuscitation.
Authorization is not required for these services.
General Limitations
Critical care provided to a neonate or a child in an outpatient setting (e.g., emergency
room) that does not result in admission should be submitted for reimbursement using
procedure codes 1-99291 or 1-99292.
If outpatient critical care (procedure codes 1-99291 and 1-99292) is provided to a client
at a distinctly separate time from another outpatient evaluation and management service
by the same provider, both services may be considered for reimbursement with
supporting medical record documentation.
Neonatal critical care (procedure codes 1-99295 and 1-99296), pediatric critical care
(procedure codes 1-99293 and 1-99294), and the initial critical care (procedure code 199291) are limited to once per day for the same provider. Subsequent critical care
(procedure code 1-99292) is for each additional 30 minutes beyond the first 74 minutes
of critical care and is limited to a total of 6 units (3 hours) per day. Neonatal and pediatric
critical care and low-birth-weight services are inpatient, per-day charges and only
allowed for reimbursement once per day by the same provider. No other inpatient
evaluation and management services will be considered for reimbursement on the same
day when submitted by the same provider.
If critical care (procedure code 1-99291) is provided by different physicians, meets the
initial 30-minute time requirement, and is provided at separate distinct times, the initial
provider's claim is considered for reimbursement. The second provider's claim is denied
but may be considered on appeal. The time spent by each physician cannot overlap, i.e.,
two physicians cannot bill critical care for care delivered at the same time. The second
physician must provide supporting medical record documentation that includes the time
during which the critical care was rendered. In addition, a statement must be submitted
indicating that the physician was the only provider managing the care of the critically ill
patient during the life-threatening crisis.
If the provider’s time exceeds the 74-minute time threshold for procedure code 1-99291
and procedure code 1-99292 may be submitted for reimbursement in addition to
procedure code 1-99291 for each additional 30 minutes. Procedure code 1-99292 may
not be submitted as a stand-alone code.
Critical care provided on the same day as a major surgery must be submitted with
documentation that the critical care was unrelated to the specific anatomic injury or
general surgical procedure.
Prolonged physician services (procedure codes 1-99354, 1-99355, 1-99356, or 1-99357)
are denied when submitted for reimbursement with the same date of service as any
critical care, neonatal intensive care, or intensive low-birth-weight (LBW or VLBW)
service (procedure codes 1-99291, 1-99292, 1-99293, 1-99294, 1-99295, 1-99296, 199298, 1-99299, and 1-99300) by the same provider.
Only the provider rendering the critical care service while the client is critically ill may
submit the critical care procedure codes for reimbursement. Although providers from
various specialties (e.g., cardiology, neurology) may be consulted to render an opinion
and/or assist in the management of a particular portion of the care, only the provider
managing the care of the critically ill patient during a life-threatening crisis may bill TMHP
for the critical care service.
Services for a client who is not critically ill and unstable but who happens to be in a
critical care unit must be submitted using subsequent hospital visit procedure codes or
hospital consultation procedure codes.
Physicians are reimbursed at the lower of the billed amount or the amount allowed by
the Texas Medicaid Program.
Advanced practice nurses and certified registered nurse anesthetists are reimbursed at
the lower of the billed amount or 92 percent of the amount allowed by the Texas
Medicaid Program for physicians for the same service.
Critical care services are subject to retrospective review.
Critical Care
Procedure codes 1-99291 and 1-99292 should be used to identify critical care services
provided to clients 25 months of age or older.
Procedure code 1-99291 should be used per day for the first 30 - 74 minutes of critical
care even if the time spent by the physician is not continuous on that day.
Procedure code 1-99292 should be used per day for each additional 30 minutes beyond
the first 74 minutes of critical care for up to 6 units or 3 hours per day. If the number of
units is not stated on the claim, only a quantity of one will be allowed.
The following services are denied as part of another procedure when submitted with the
same date of service as hospital critical care evaluation and management procedure
codes 1-99291 and 1-99292:
Table A: Procedure Codes
2-36000
2-36410
2-36415
2-36540
2-36600
2-43752
4/I/T-71010
4/I/T-71015
4/I/T-71020
1-90940
1-92002
1-92004
1-92012
1-92014
1-91105
1-92953
5-93040
T-93041
I-93042
5/I/T-93561
5/I/T-93562
1-94002
1-94003
1-94660
1-94662
5-94760
5-94761
5-94762
5/I-95833
1-99090
Claims for seemingly improbable amounts of critical care (procedure code 1-99292) on
the same date may be subject to review to determine if the physician has filed a false
claim.
Pediatric Critical Care
Procedure codes 1-99293 and 1-99294 are used to identify pediatric critical care
services provided to clients 29 days through 24 months of age.
Pediatric critical care services are comprehensive per diem (daily) care procedure codes
for providers personally delivering or supervising the delivery of care of the critically ill
infant or child.
Pediatric critical care procedure codes 1-99293 and 1-99294 will be denied when
submitted by any provider on the same day as neonatal intensive care (procedure codes
1-99295 and 1-99296), low-birth-weight (procedure codes 1-99298, 1-99299, or 199300), or critical care (procedure codes 1-99291 and 1-99292) services.
Inpatient pediatric critical care (procedure codes 1-99293 and 1-99294) is a per-day
charge. If an inpatient evaluation and management service is submitted with the same
date of service as pediatric critical care by the same provider, the inpatient evaluation
and management procedure code is denied.
Separate charges for any of the following procedure codes submitted with the same date
of service as pediatric critical care (procedure codes 1-99293 and 1-99294), neonatal
intensive care (procedure codes 1-99295 and 1-99296) or intensive (noncritical) lowbirth-weight services subsequent intensive care (procedure codes 1-99298, 1-99299, or
1-99300) will be denied as part of another procedure:
Table B: Procedure Codes
2-31500
2-31502
2-36000
2-36400
2-36405
2-36406
2-36410
2-36415
2-36420
2-36430
2-36440
2-36510
2-36540
2-36555
2-36600
2-36620
2-36625
2-36640
2-36660
2-43752
2-51000
2-51005
2-51010
2-51701
2-51702
2-62270
2-62272
4/I/T-71010
4/I/T-71015
4/I/T-71020
1-90760
1-90761
1-90765
1-90766
1-91105
2-92953
5/I/T-93561
5/I/T-93562
1-94002
1-94003
5/I/T-94375
1-94640
1-94642
1-94644
1-94645
1-94660
1-94662
1-94664
5-94760
5-94761
5-94762
1-99090
Neonatal Critical Care
Procedure codes 1-99295 and 1-99296 are used to identify neonatal critical care
services provided to clients 28 days of age or younger.
Procedure code 1-99295 may be considered for reimbursement once per lifetime per
critically ill neonate on the date of admission.
Procedure code 1-99296 may be considered for reimbursement once per day per
critically ill neonate and will be denied when submitted with the same date of service as
1-99295.
Procedure codes 1-99295 and 1-99296 may be used only during the period of time the
neonate is considered to be critically ill.
After the neonate is no longer considered critically ill, the evaluation and management
procedure codes for subsequent hospital care (procedure codes 1-99231, 1-99232, or 199233) may be used.
The same provider may submit the neonatal critical care procedures for no more than 28
days. After the 28th day, providers must submit pediatric critical care procedure codes
(procedure codes 1-99293 and 1-99294).
Neonatal intensive care procedure codes are considered for reimbursement once a day
regardless of the time that the physician spends with the neonate. Critical care
procedure codes submitted with the same date of service as neonatal intensive care
procedure codes will be denied regardless of provider.
Refer to Table B above for separate services that will be denied as part of another
procedure when submitted with neonatal critical care procedure codes.
The following procedure codes submitted with the same date of service by the same
provider may be considered for reimbursement in addition to neonatal intensive care:
(This is not an all-inclusive list)
Table C: Procedure Codes
2-31720
2-31730
2-32000
2-32020
2-36450
2-36455
2-49080
2-49081
2-61000
2-61001
Intensive (Noncritical) Low-Birth-Weight Services
Those services provided to infants that are LBW or VLBW, and that no longer meet the
definition of “critically ill” but continue to require intensive observation and frequent
services and interventions only available in the intensive care setting, may be submitted
for reimbursement using procedure codes 1-99298, 1-99299, and 1-99300.
Neonatal intensive (noncritical) low-birth-weight services (procedure codes 1-99298, 199299, and 1-99300) may be considered for reimbursement daily for subsequent
neonatal (noncritical) services, regardless of the time that the physician spends with the
neonate or infant. Providers should use the procedure code appropriate for the present
body weight and intensity of service required by the neonate or infant.
Refer to Table B above for separate services that will be denied as part of another
procedure when submitted with the same date of service as neonatal intensive
(noncritical) low-birth-weight services procedure codes.
Newborn Resuscitation
Procedure code 1-99440 is used to identify newborn resuscitation services.
Procedure code 1-99440 should be used by the physician who provides resuscitation
care to the high-risk newborn.
Newborn resuscitation (procedure code 1-99440) will be considered for reimbursement
when submitted with the same date of service as neonatal critical care (procedure codes
1-99295 and 1-99296).
The following procedure codes will be denied if submitted with the same date of service
as procedure code 1-99440:
Table D: Procedure Codes
1-99221
1-99222
1-99223
1-99231
1-99232
1-99233
For more information, call the TMHP-CSHCN Contact Center at 1-800-568-2413.
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