Effective May 26, 2021, CMS removed Internet-Only Manual (IOM) Publication 100-04, Section 30.6.12 concerning guidance on critical care services. Medicare will continue to provide coverage for critical care services. Billing Medicare for a critical care service requires the selection of the code that best represents the level of E/M service performed. Selection of the E/M code that best represents physician work as described by the Current Procedural Terminology (CPT) Manual published yearly by the American Medical Association and further clarified by the CMS Evaluation and Management Guidelines published in 1995 and 1997.
Per the CMS Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.1 A, "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. All E/M services reported to Medicare must be adequately documented so the medical necessity is clearly evident. Federal law requires that Medicare not pay for services for which the documentation does not establish medical necessity. For E/M services medical necessity of a visit as well as the CPT “level” of the service must both be documented. Providers should continue to follow Current Procedural Terminology (CPT) guidance.
CMS defines medical necessity as health care services or supplies needed to:
- Diagnose or treat an illness, injury, condition, disease, or its symptoms; and
- Meet accepted standards of medicine.
The removal of this information is in response to a petition received in January by the U.S. Department of Health and Human Services (HHS). This is pursuant to the HHS Good Guidance Practices Regulation. CMS responded to the petition by withdrawing these manual sections and plans to address the topics therein through notice-and-comment rulemaking. Until such guidance is published, Medicare will continue to cover these services.
Novitas Solutions will continue to update the provider with additional information as received.
Please refer to the following article released by CMS for additional information, “CMS Notice Regarding Split (or Shared) Evaluation and Management Visits and Critical Care Services from May 26, 2021 through December 31, 2021.