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Critical info on billing critical care

How many of your claims are being downcoded?


Published in the May 2016 issue of Today’s Hospitalist

WE KNOW that reporting critical care services can be a challenge, but recent reviews have uncovered some troubling statistics. In 2014, National Government Services (NGS)—the Medicare administrative contractor for Illinois, Wisconsin and Minnesota—conducted a four-month prepayment review of critical care claims.

NGS found that the average error rate for those claims was an astonishing 62%. And last year’s numbers weren’t any better: An interim prepayment review done over several months in 2015 revealed that the average error rate had jumped to 71%.

The claims found to be in error were often recoded to subsequent hospital visit codes, which of course are paid much less. The primary reason cited for errors was that documentation did not support critical care.

So what’s going on? Are physicians unsure about what constitutes critical care services? Or are they just flubbing their documentation and not making a convincing case that they’re rendering critical care?

I think the answer is both, equally. To make sure you’re not leaving money on the table, let’s review some critical care decision-making and documentation basics.

Putting “what ifs” aside
As hospitalists, you were trained to think about the “what ifs” and the “might happens.” But critical care services (99291: critical care, evaluation and management, first 30-74 minutes; 99292: each additional 30 minutes) are different: You have to set aside the “what ifs” because they may never occur. Instead, you need to focus on the patient’s current condition and what immediate interventions are needed to manage that condition and prevent further deterioration.

As defined by CPT, critical care is the “direct delivery of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in a patient’s condition.”

Circumstances that may require critical care can include 
failure or collapse; 
shock; renal, hepatic or respiratory failure; or profound neurological 
impairment that compromises other organ systems.

To determine whether you’re providing critical care services, ask yourself the following:

    • Is my patient unstable at this time due to blood pressure, heart rate or rhythm, respiratory status, pulse oximetry, renal function, central nervous system impairment, or lab values?
    • Is this patient currently experiencing a life-threatening deterioration or failure of one or more major organ systems?
    • Does this patient have a high probability of experiencing a life-threatening deterioration or failure of one or more major organ systems without an immediate intervention?If you don’t answer “yes” to at least one of those questions, reporting critical care services may be inaccurate or inappropriate.

Is it critical care?
Critical care time is reported per date of service and represents an aggregate of the time spent in critical care services on that date. But even if you provide such services to a patient in the morning, that doesn’t mean you can bill critical care for a second visit later that day when the patient has stabilized.

Just because a patient is in a critical care setting such as the ICU or CCU doesn’t mean their condition warrants critical care. But critical care services do require a physician to devote his or her full attention to the patient. You cannot provide care or other services to other patients during the same period of time.

When determining whether or not to report critical care, don’t associate “critical care” with a specific diagnosis or condition. Patients may have a significant
 illness or injury and still present as clinically stable.
 Report the service that best represents the care and
 treatment you are providing to the patient in front of 
you, not the patient who “might” develop a significant 
problem or experience a life-threatening deterioration.

Patients may, for example, be on IV medications for blood pressure support, and the fact that they require medication to support their blood pressure may classify them as being critically ill. But if their pressure is well-maintained, their other clinical parameters are normal and they feel well, they are not currently facing a high probability of life-threatening deterioration or imminent death that requires an immediate intervention. In such cases, you shouldn’t bill critical care services.

What you need to document
Documentation must reflect the total critical care time you spend with the patient. You cannot count time spent updating the family regarding the patient’s condition. You may report time with the family only when patients are unable to make decisions on their own and the family must assume decision-making responsibilities.

When documenting critical care services, be sure to include:

    • Patient status. What is the patient’s present condition, and which systems are failing or are at high risk to fail? Your documentation needs to address those issues and state why the services you provided were necessary to prevent life-threatening deterioration. Also, make sure your documentation encompasses all the diagnoses you are managing.
    • Clinical decision-making. Document in road-map fashion all the clinical elements you considered that reflect the highly-complex medical decision-making required for critical care. This may include analyzing lab results and diagnostic tests, coordinating treatment with other professionals involved in that patient’s care, interpreting data, and providing specific interventions to prevent the patient from imminent deterioration.
    • Your time. Time is an essential factor in reporting critical care services. Document the total number of minutes spent. You may also report your time as “start time” and “stop time.”Also, make sure that documentation of services not included in critical care time is separate and distinct.

What do critical care codes include?

CRITICAL CARE CODES include the following services, which are not separately billable when performed on the same date as critical care:

  • interpretation of cardiac output measurements (CPT 93561, 93562);
  • chest X-rays, professional component (CPT 71010, 71015, 71020);
  • blood draw for specimen (CPT 36415);
  • blood gases, and information data stored in computers such as ECGs, blood pressures, hematologic data (CPT 99090);
  • gastric intubation (CPT 43752, 91105);
  • pulse oximetry (CPT 94760, 94761, 94762);
  • temporary transcutaneous pacing (CPT 92953);
  • ventilator management (CPT 94002–94004, 94660, 94662); and
  • vascular access procedures (CPT 36000, 36410, 36415, 36591).

More on billing for advance care planning

EARLIER THIS YEAR, at least one Medicare administrative contractor incorrectly claimed that advance care planning services could be billed only in the outpatient setting.

The Centers for Medicare and Medicaid Services has since issued clarifications about the advance care planning codes (99497-99498). First, Medicare has put “no place of service limitations” on where advance care planning services can be furnished or billed. Further, “The codes are separately payable to the billing physician or practitioner in both facility and nonfacility settings and are not limited to particular physician specialties.”

Sue A. LewisSue A. Lewis, RN, CPC, PCS, has more than 40 years of health care experience.