This series will be a running feature highlighting billing, coding, practice management, and other business aspects of neurocritical care. 

Although all of us received extensive education and training in the care of neurocritical care patients, few if any of us received any training on the non-patient care aspects of our daily jobs. The goal of this series will be to increase your value as a neurocritical care provider to your organization while improving regulatory compliance and hospital-based metrics.

Physician neurointensivists come from a variety of specialties and similarly are housed in a variety of hospital departments, such as neurology, neurosurgery, anesthesia, and critical care. Therefore, in any given situation it is possible that a neurointensivist and another colleague in their department may be caring for the same patient on the same date. From a billing standpoint, it is important that a neurointensivist has his or her taxonomy code (how a physician’s specialty is identified by CMS and third-party payers) correctly reflect that he/she is a neurointensivist (which is now a recognized specialty, utilizing code 2084A2900X) and not their original specialty, as CMS and third-party payers may perceive that two neurologists (e.g., a stroke neurologist and a neurologist neurointensivist) or two anesthesiologists (e.g., one who provided perioperative anesthesia and a separate anesthesia neurointensivist) from the same practice billed for the same patient on the same date of service, resulting in rejection of one or both provider’s charges.

Providers can check their own taxonomy code through the NPI Database at: https://npidb.org/doctors/allopathic_osteopathic_physicians/neurocritical-care_2084A2900x/

It is easy and free to change it. The provider can list neurology, anesthesia, etc. as their secondary specialty, and there are no negative ramifications of practicing general neurology or another specialty when one’s primary taxonomy code is listed as neurocritical care.  Of note, however, there are no specialty codes for advanced practice providers.

Once a physician’s taxonomy code has been confirmed as correct, he or she must notify their hospital credentialing department to re-register the physician with every insurance carrier as a neurointensivist, which will likely take a couple of months.

From a practical standpoint, this simple change will allow for two providers in the same department to bill for the same patient on the same date of service provided their care does not overlap. To illustrate this point, a common case scenario is described below:

An intubated patient is brought to the emergency department by EMS as a stroke alert. The stroke neurologist evaluates the patient and identifies that the patient has an intracerebral hemorrhage, is hypertensive, and is on an anticoagulant. The stroke neurologist orders prothrombin complex concentrate (PCC), puts the patient on nicardipine, and notifies the neurointensivist to assume care and admit the patient to the ICU.

For this case, the stroke neurologist can bill critical care for the decision-making needed to evaluate this patient with a life-threatening neurological condition, as well as reviewing the neuroimaging and initiating the treatment needed to prevent the patient from dying or having worsening brain injury (i.e., ordering PCC and nicardipine).

The neurologist neurointensivist can now come evaluate the patient, document a history and physical, and bill for acute respiratory failure as their admission diagnosis as they optimize the ventilator settings. Both physicians can bill 99291 (30-74 minutes of critical care) and each will be credited for 4.5 work relative value units (wRVUs) by ensuring that they bill for a different primary diagnosis even if the secondary diagnoses are the same. This fiscally mindful approach should be the starting point for designing care teams and delineation of duties at the hospital.

It is important to note that most electronic medical record systems can now integrate with reporting systems to reflect only the wRVUs which resulted in a charge collection. In other words, they can exclude provider work which was rejected by the insurance company despite the physician’s documentation. Moreover, nearly every health system tracks provider wRVUs and uses them in some form or another to justify full-time equivalents (FTEs), salaries, bonuses, etc. Therefore, neurocritical care providers must also become masters of documentation to capture all appropriate billing and wRVUs.

To bill for critical care, one must start with the definition of critical care

• The patient must be critically ill, with anillness or injury that acutely impairs 1 or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition.
• The provider must treat the critical illness using high complexity decision-making to assess, manipulate, and support vital systems to treat single or multiple vital organ system failure and/or prevent further life-threatening deterioration of the patient’s condition.
• The care requires the personal attention of the provider. Care must be provided at the bedside or on the floor/units where the patient is housed.
• The care must be medically necessary. Treatment or management of the patient’s imminent deterioration is required.

From a practical perspective, critical care can be thought of as any situation in which there is a risk of organ damage or death if the provider were not standing at the bedside manipulating medications, treatments, therapies, or interpreting complex data and diagnostics.

What counts as critical care billing?

• Time at the bedside spent examining the patient. Time spent in the unit reviewing the patient’s history, images, medications, labs, etc.
• Time spent obtaining history from the patient’s family (in person, not via telephone) if the patient is unable to provide it
• Time spent documenting if it is done on the unit where the care was provided (i.e., not from home later that evening)
• Time discussing the plan of care or subsequent medical decision making (e.g., discussing the possibility of intubation, PEG tube, comfort care), but not including updating the family

What does not count as critical care billing?

• Time associated with a procedure (e.g., sedating a patient for intubation) is bundled into the procedure’s CPT code
• Time spent caring for a patient in the ICU who no longer meets the definition of critical care
• Any time that involves speaking on the telephone with family or other providers (encounters must be face-to-face or via telemedicine)
• Time spent updating the family on a patient’s condition without discussing goals of care, treatment options, etc.

Additional documentation pearls

• Care does not have to be provided in the ICU
  • Example #1: A patient admitted to the floor develops respiratory distress, is nasotracheally suctioned, placed on BiPAP, and transferred to the ICU (if care was provided by the provider at bedside, not just ordered for RT to do it) with total time of at least 30 minutes
  • Example #2: A patient with a high NIH Stroke Scale presents to the emergency department and the provider evaluates the patient for tPA and the possible need for intubation/pressors (which can be done in the ED)
• Buzzwords and phrases to avoid in critical care documentation. Appropriate word or phrases listed in parentheses.
• “Update” (instead: “discussed options of care, including…”)
• “Stable” (instead: “unchanged”)
• “History of” (instead: “with … [list active problems as appropriate]”)
• “Unable to assess” (instead: “unable to assess as the patient is unconscious”) 

Given most neurocritical care units utilize a multi-disciplinary care team, it is important to understand how a given provider can bill. Understanding the concept of split-shared visits is fundamental to this process. For critical care, the provider is billing for the work done by him or her only.  In the case of attending physicians, do not acknowledge the APP’s note if you are attesting an APP’s note.  Based on local practice guidelines, a physician’s note may be separate or part of the same document as the APP’s or resident’s when only one charge is being submitted. Critical care is an example of when split-shared visits are not allowed. Therefore, it is recommended that the provider document in the first person using “I” to clearly state what he or she did.

In contrast, Evaluation and Management (E&M) charges used for non-critical care patients on the floor do allow for split-shared visits. In other words, if a non-critical care floor patient received most of their care on a given date of service and an attending physician briefly re-examines the patient and confirms the APP’s plan of care, the attending physician can bill for the cumulative work done by both the APP and him or herself.

Further elaboration on documenting and billing within an APP-led service, resident-led service, fellow-led service, and multi-physician-led service will be discussed in a future article.

Ryan Hakimi, DO, MS, NVS, RPNI, CPB, FNCS is the Director of the Neuro ICU and TCD Services and an Associate Professor at the University of South Carolina School of Medicine-Greenville/Prisma Health-Upstate. He is also a Certified Professional Biller (CPB) through the American Academy of Professional Coders and CPT Advisor to the AMA and RUC.

​