COVID-19 and the Anesthesia Department (part2)

COVID-19 and the Anesthesia Department, Part 2

So now, you as an anesthesiologist, have been asked to assist with providing patient care in the hospital ICU (or elsewhere in the facility). Most anesthesiologists haven’t provided E/M services since medical school, much less critical care services and need guidance as to how to document and bill their care. Below are some general guidelines with resources for additional important information. Please note the guidelines for critical care are complex (critical care medicine occupies 10 pages in the CMS Manual) and is beyond the scope of this brief introduction. However, a broad understanding is foundational for additional learning. Please take the time to review the materials provided by way of links included. 

Critical Care Services are Time-based

Like anesthesia services, critical care services, CPT codes 99291 and 99292, are time-based.  However, that’s where the similarities end. 99291 and 99292 are evaluation and management codes (E/M codes) used to report medically necessary services to a critically ill patient. 99291 is used to report critical care services of duration between 30 and 74 minutes, after which 99292 would be considered for EACH 30 minutes after the 99291 is reported during the same calendar day (see table for additional time in the Novitas document included).  

Critical Care Services are Reserved for Critically Ill Patients

The first key to billing critical care is understanding what the definition of a critically ill patient is. This seems like an overly obvious statement, but by definition, these are patients where “there is a high probability of sudden, clinically significant, or life-threatening deterioration in the patient’s condition which requires the highest level of physician preparedness to intervene urgently.”

The Types of Services Qualify as Critical Care

Next, we must understand what treatment qualifies. Again, by definition: “Critical care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life-threatening deterioration in the patient’s condition.” (CPT definitions)

Also understand the fact the patient is critically ill IS NOT enough reason alone to bill critical care. The provider needs to be aware of the following criteria for critical care:

  • The care of such patients involves decision making of high complexity to assess, manipulate, and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple vital organ system failure or to prevent further deterioration.”
  • It may require extensive interpretation of multiple databases and the application of advanced technology to manage the patient.
  • Critical care services include but are not limited to, the treatment or prevention or further deterioration of central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic or respiratory failure, post-operative complications, or overwhelming infection.

Other Important Aspects of Critical Care Services:

It’s important to note that critical care IS NOT billable simply because the patient is in the ICU.

Nor must the patient be in the ICU to bill critical care. It’s all about whether the patient is critically ill and whether your services meet the terms of critical care as opposed to being assigned to the ICU.  

Services that don’t meet the critical care threshold (i.e., less than 30 minutes or failure reach the aforenoted criticality thresholds) should be considered in light of subsequent hospital care codes 99231-99233.

Certain procedures ARE BUNDLED with critical care services. DO NOT unbundle these (i.e., don’t bill them separately). These include ventilator management and vascular access procedures (a list is found in the AAPC link below). Be very careful with ventilator management (CPT codes 94002-94660 and 94662). Vent management IS BUNDLED with critical care medicine (see page 58, N) and cannot be billed separately.    

Certain procedures ARE UNBUNDLED with critical care services. However, as mentioned elsewhere below, the clock needs to stop to back out the time taken to perform these procedures. Examples of unbundled procedures include CPR and intubation (see “Commandment” 7 & 9 in AAPC’s Ten Commandments of Coding Critical Care below). 

We’ll need to consider using modifiers -25 (critical care preoperatively/postoperatively) as appropriate for patients the practice may have provided anesthesia for within the same calendar day (see pages 57 & 58 K). Requirements differ from carrier to carrier.

Qualified Non-Physician Practitioners (NPPs) MAY be able to render critical care. “Critical care services may be provided by qualified NPPs and reported for payment under the NPP’s National Provider Identifier (NPI) when the services meet the definition and requirements of critical care services in Sections A and B. The provision of critical care services must be within the scope of practice and licensure requirements for the State in which the qualified NPP practices and provides the service(s).” (from Medicare Manual page 51, D)

Details About Time:

Time spent providing critical care services require the clinician’s FULL attention to the patient and cannot be split with any other patient related care (i.e., provider cannot be managing anesthesia cases or other patients  concurrent with critical care services etc.).

Time can be an aggregate during the same calendar day… including services provided by members of the same practice. Start and stop times should be documented in the patient’s record.

Time spent performing services not bundled with critical care “stop the critical care clock.” Resume the clock after the procedure is performed as necessary.

Time spent with family may or may not be billable (see Novitas material for conditions).   

Time spent receiving or giving briefings about the patient from/to other clinicians are generally billable, but the provider should read and understand the applicable guidelines provided in the additional reading material below. Time must be documented in the patient’s records/progress notes (as well as other relevant clinical information).   

Documentation Requirements:

The Clinician is expected to clearly document the need for critical care services and what they did to treat the patient. Typically, this would include: 

  • A description of all of the physician’s interval assessments of the patient’s condition;
  • Any impairments of organ systems based on all relevant data available to the physician (i.e. symptoms, signs, and diagnostic data);
  • The rationale and timing of interventions; and
  • The patient’s response to treatment.

That’s probably about all that can reasonably be covered in overview fashion. If the clinician has questions, don’t hesitate to reach out to us at Anesthesia Resources.


Below are important resources cited above. The clinician is highly encouraged to familiarize themselves with the additional guidance provided in the source data below:






Anesthesia Groups Response to COVID-19 (part1)

Impact on Manpower and Staffing

Right-sizing the staff of an anesthesia practice is probably the greatest challenge you will face during this COVID-19 outbreak.  Since your staffing must be proportionate to the volume of anticipated surgical work, this virus poses a huge problem on two levels.  First, what is the right staffing for anticipated case volume for the next few months and how does one change the staffing model so quickly?  Nothing is more painful than having to lay off staff, especially if they will be needed later in the year.  Unfortunately, not many practices can carry unneeded personnel for more than a few weeks.

To this end, I have the following suggestions many of our clients are exploring various options to avoid mass lay-offs.  Here are some of the options being discussed:

  • Asking staff to use their accrued PTO time
  • Giving staff the option of shifting from salaried status to hourly with reduced hours (with a minimum guaranteed number of hours)
  • Extensive furloughs (leave without pay, with a position held open for the employee’s return)
  • Exploring other options within the facility, such as ICU care and respiratory management
  • Exploring changing the 401K to allow employee loans or withdrawals without plan penalties (federal and state taxes and penalties still apply).

The anticipated surgical volume is the key. No cases, means you need to reduce staffing. The staff should know what the plan is and what is expected of all providers to get through this crisis.  We are actively working with our clients to assist with the formulation of a plan to insure the long-term viability of the groups we service.

Maximizing Available Cash Flow

In an effort to minimize the disruption to your staff, and to avoid mass lay-offs and to shorten the long term impact to the business, many of our clients are exploring financial mechanisms that will allow them to weather this current storm.

In cash flow projections, many groups are contacting their accountants, third-party administrators and legal counsel to understand the following specifics for their practice:

  • What profit sharing or 401k contributions is the group required to make, and can that timeline be extended? Many groups fund generous profit-sharing contributions early in the year. With appropriate tax planning, this deadline can often be extended into the fall.
  • Can the group obtain or expand a line of credit? While available cash may only sustain the groups for a couple of weeks, a line of credit will help many groups continue to fund some payroll when the reduced cash flow is realized.
  • What provisions exist in their hospital contracts that will be trigged by this predicted reduction in volume? Many client contracts contain revenue guarantees that are reviewed periodically throughout the year. Understanding what triggers these clauses and working with the hospital during these challenging times could allow the group to collaborate with the hospitals when and if emergency funds become available.
  • What expenses can be eliminated of decreased temporally?

Other Clinical Options

In some facilities there is a discussion of anesthesia staff helping manage an increase in COVID-19 patients suffering from respiratory complications.  This would essentially represent ICU level services.  These involve a very different billing mechanism for that applicable to anesthesia.  Physician providers can bill either ICU codes (99291 and 99292) or subsequent hospital visit codes.  Payment for these codes is less than for anesthesia services.  Providers exploring such an option should carefully evaluate the specific requirements and clearly understand the documentation issues before proceeding.