Coding Corner: Collect the Reimbursement You Deserve for Concurrent Critical Care

Here’s the key: Make sure doctors are providing different services

Have you fallen for the myth that two providers can’t bill for critical care for the same patient during the same time period?

Get the facts: Nothing in the Centers for Medicare & Medicaid Services manual, or other sources, says two or more providers can’t bill for concurrent critical care, says Betsy Nicoletti with Medical Practice Consulting in Springfield, Vt.

You should make sure to consult your local carrier’s policies. Some carriers do require that providers be from different specialties to provide critical care at the same time, Nicoletti says.

Often, physicians from different specialties, such as nephrology, cardiology and pulmonology, will treat the same patient at the same time, Nicoletti says. And if the patient is critically ill and requires life-saving treatment, they all should be able to bill.

Some multispecialty practices may hesitate to bill for critical care services by two different physicians at once, Nicoletti says. But if you downgrade one of the two doctors’ services to a subsequent visit code, you could be losing out on your rightful reimbursement.

Caution: You should make sure the doctors are providing different services, says Maggie M. Mac, CMM, CPC, CMSCS, a consultant with Pershing Yoakley & Co. in Clearwater, Fla. If two or three doctors all say they did exactly the same thing, it won’t hold up in an audit.

For example: One doctor could be reviewing tests and recommendations and checking the patient’s vital signs. In the meantime, a second doctor could be examining the patient and reviewing her ongoing care and “medical management,” Mac says. 

Or if the patient has multiple problems, such as diabetes, hypertension and heart failure, different physicians could be providing critical care in different areas, Mac adds.

Bottom line: Your doctors must be providing critical care to critically ill patients. The fact that a patient is in the intensive care unit (ICU) does not automatically qualify any treatment as critical care, Mac says. The physician’s services have to be crucial for maintaining the patient’s life and preventing “loss of body function or organ-system failure.”

- Published on 2007-05-24