Just as 2022 restructured the rules associated with outpatient billing and documentation, January 1, 2023, begins with substantial changes that surround inpatient billing and documentation. In general, the identity and history associated with patients who present to the emergency department is often unknown. As such, items that have historically been required for documentation within the H&P such as the review of systems, social history, and family history often cannot be obtained at the time of documentation leading to queries from the billing and coding specialists within the hospital and often lead to downgrading of the charge and provider frustration.

With the new changes, only relevant history needed for the care of the patient needs to be documented when billing an Evaluation and Management (E&M) code. For example, the family history of an 80-year-old ICH patient is irrelevant to the patient’s care and no longer needs to be documented in the H&P. However, when known, documenting this patient’s use of antithrombotics and antihypertensives is relevant and should be documented. Many centers will thus need to restructure their H&P fields to consolidate the fields down to relevant medical history. Here we summarize the variety of inpatient encounter types considering the most up to date requirements.

E&M Encounters With APPs

It is important to note that when an attending physician attests an APP’s note during an E&M encounter that he/she document that they performed the substantive portion of the assessment. This simple attestation would then require that the APP’s note document what the physician did. As an alternative, and to ensure compliance with this requirement, it is ideal for the attending physician to document at least one of the 3 key elements (the history, physical exam, or the assessment and plan). Therefore, an ideal E&M attestation with an APP would state, “I saw and examined this patient on month/day/year. I have reviewed the note from APP X. I agree with his/her assessment and plan except as noted here. On my examination… OR summarize the history of present illness OR summarize the assessment and plan.”

E&M Encounters With Residents/Fellows

For an E&M encounter with a resident or fellow, the attending needs to be physically present for the critical or key portions of the services provided by the resident or fellow and document the attending’s involvement in the management of the patient. As in the case with attestation of an APP’s E&M service, the attending may document, “I saw and evaluated this patient on XX/XX/XXXX. Discussed with the resident/fellow and agree with the findings and plan as documented in the resident/fellow’s note.” However, again this would require that the resident/fellow clearly document what the attending did. Therefore, as in the case of the APP, it is best for the attending to document one of the 3 key elements in their attestation.

For critical care patients, those additional history items have never been required for billing critical care, but some health systems have had internal requirements that have mandated that all of the fields be completed leading to provider frustration. Additionally, 2022 marked the allowance of split-share billing with APPs (counting critical care time provided by the APP alone + critical care time provided simultaneously by the attending and APP + critical care time provided by the attending alone). This change led to substantial frustration and many questions. Therefore, in 2023 CMS and CPT offered some clarifications.

New since January 1, 2023, are two key points of clarification regarding time thresholds for billing the add-on code 99292 for CMS patients in comparison to non-CMS patients. First, CMS has a differing opinion than the CPT Committee in that they feel that 99292 can only be billed when a complete additional 30 minutes time increment is met as shown in Table 2.  Second, CMS indicated that 99292 can be billed when the appropriate time threshold is met regardless of whether the time is provided by one individual or as a split-share visit and does not require the first provider to provide at least 30 minutes.

Non-CMS Patient: Critical Care Provided by APP and Attending in the Same Group

First practitioner (APP or attending) provides first 30 minutes of CC time

Bill 99291 (30-74 minutes) by the practitioner who provided the most critical care time

• Ex: APP sees patient first and provides 35 minutes of critical care time; then attending provides critical care with the APP/completes documentation for 38 minutes of critical care time. Total CC time is 73 minutes which gets billed to the attending

Bill 99291 and 99292 (total time 75-104 minutes)

• Example 1: APP sees the patient first and provides 35 minutes of CC time; then attending provides critical care with the APP/completes documentation for 45 minutes of critical care time. Total CC time is 80 minutes which gets billed to the attending.
• Example 2: Physician A provides 45 minutes CC; Physician B provides 40 minutes of critical care on the same calendar day: total time spent 85 minutes. Physician A would bill code 99291 and Physician B would bill code 99292 x 1 unit.
• Example 3: Physician A provides 100 minutes CC; Physician B provides 30 minutes of CC on the same day: total time spent 130 minutes. Physician A would bill code 99291 and 99292 x 1 and Physician B would bill code 99292 x 1 unit.

Table 1: Non-CMS billing table (not Medicare or Medicaid)

Table 2: CMS billing table (Medicare or Medicaid)

New since January 1, 2023, is the allowance of summing of critical care time under split-share when the first practitioner (APP or attending) does not provide at least 30 minutes of CC time. In this case one must follow the rules below:

First practitioner (APP or attending) provides less than 30 minutes of CC time

Bill 99291 (30-74 minutes) by the practitioner who provided the most critical care time

• Ex: APP sees patient first and provides 15 minutes of critical care time; then attending provides critical care with the APP/completes documentation for 35 minutes of critical care time. Total CC time is 50 minutes which gets billed to the attending.

Bill 99291 and 99292 (104-134 minutes)

• Ex: APP sees the patient first and provides 25 minutes of CC time; then attending provides critical care with the APP/completes documentation for 80 minutes of critical care time. Total CC time is 105 minutes which gets billed to the attending.

Bill 99291 only (74-103 minutes)

•  Ex: APP sees the patient first and provides 25 minutes of CC time; then attending provides critical care with the APP/completes documentation for 60 minutes of critical care time. Total CC time is 85 minutes which gets billed to the attending. Note that since the first provider did not provide at least 30 minutes of CC time and the sum of the two providers CC time is less than 104 minutes, only 99291 can be billed.

It is important to note that each institution can choose if they wish to follow CMS rules for all payers or to bill each individual payer by that payer’s rules. In other words, your institution may indicate that you must bill for 104 minutes of critical care in order to bill a 99292 even if the patient is covered under a commercial insurance carrier such as Blue Cross. Please consult your hospital’s billing and coding department to ensure compliance.