What about Midnight? Billing for Time Across Calendar Days What about Midnight? Billing for Time Across Calendar Days

What about Midnight? Billing for Time Across Calendar Days

David Carpenter, MPAS, FCCM, DFAAPA, PA-C, CPC

This auditing and compliance “Tip of the Week” was originally published by the National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.

What about Midnight? Billing for Time Across Calendar Days

With the advent of 24/7 coverage in the ICU, one contentious issue is how to bill for services that start just before midnight. In this audit tip we will discuss how  CPT handles these services and how time based billing applies to other E/M services.

What about Midnight?

For Evaluation and Management (E/M) services, the calendar day is defined as lasting from midnight to midnight. All services start at midnight and end before midnight on the same calendar day. The issue becomes – what happens if a service starts before midnight and continues across midnight into the next calendar day? A common scenario is a patient who arrives and is seen in the ICU at 11:40 pm. In order to bill for the first hour of critical care (99291), at least 30 minutes must be spent providing critical care for the patient. Obviously given the time of arrival, it is not possible for 30 minutes to be spent between when the patient is first seen and midnight. There are three methods to handle this situation:

1. For critical care that does not meet the 30-minute threshold, appropriate E/M codes can be used such as initial hospital care (99221-99223).

2. If the patient is being admitted through the ER or some other venue the provider can go to that site and provide medically necessary services, starting the critical care time when they see the patient.

3. A third method involves the CPT definition of time. For time-based codes such as critical are (99291-99292) CPT states “that for services measured in units other than days extend across calendar days. When this occurs a continuous service does not reset and create a first hour. However, any disruption in the service does create a new initial service. [1]” Simply put, time that starts before midnight and is continuous past midnight is billed on the calendar day it starts.

For this scenario, the patient arrived at 11:40 pm and was critically ill. The provider renders critical care services until 12:35 am (55 minutes). At that time they are called away to see another patient. The provider then returns to the bedside and spends another hour (60 minutes) providing critical care services.

In this case the provider will bill first hour critical care (99291) on the calendar day the patient arrived (ICU day 1) and another first hour critical care (99291) on the next calendar day (ICU day 2). Alternatively if the provider had performed 2 hours of continuous critical care services they would have billed a 99291 (first 74 minutes) a 99292 (next 30 minutes) and another 99292 (remaining 16 minutes) on the initial admit day.

Prolonged Services

Another time-based code used in the inpatient setting is the prolonged services code (99356-99357). In this case, once the threshold for the initial E/M code is surpassed by at least 30 minutes a prolonged service code can be added to the initial E/M code.

For example, a patient is transferred from an outside hospital for further care and arrives at 11:20 pm. The patient is not critically ill but very complex with a 21-day stay at the outside hospital. The provider spends two hours examining the patient, entering orders, reviewing outside medical records and ordering consults. The initial E/M code is 99223 (initial hospital care level 3). The time associated with that code is 70 minutes. Since the provider spend an additional 50 minutes in medically necessary services and the time was continuous, a prolonged service inpatient code – 99356 (first hour) can be added on to the initial service day.


The key to documentation for these services is to document that the service was continuous and started before midnight. In addition all other documentation requirements for critical care or initial inpatient services must be met.

The use of continuous time is a powerful tool to help increase provider payment and ensure providers are properly reimbursed for the services they perform. In addition to recognizing the situation, proper documentation of time spent is the key to reimbursement for these services.

[1] American Medical Association, Current Procedural Terminology 2019 edition

This Week’s Audit Tip Written By:

David Carpenter, MPAS, FCCM, DFAAPA, PA-C, CPC

Mr. Carpenter is a PA intensivist in the Atlanta, GA area transplant/surgery ICU. Mr. Carpenter has considerable experience in pediatric and adult GI, liver transplant surgery, and surgical intensive care. Mr. Carpenter will be a speaker at the upcoming NAMAS 11th Annual Auditing & Compliance Conference in Clearwater Beach, FL.

What to do next…

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  2. Read more: What can you expect from a coding and compliance review?
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