ED Coding and Reimbursement Alert

Many MACs are already reviewing these claims.

If you’re worried about your critical care service claims, consider performing an internal audit to make sure you’re documenting, coding and billing these services by the book. A quick survey of your billing rates can help you fix coding issues and improve your bottom line, too.

TPE: Currently, critical care service claims are under Targeted Probe and Educate (TPE) medical review for Part B MACs who’ve published their active lists like CGS Medicare, Novitas Solutions, and Palmetto GBA.

RAC & CERT: In addition, there are three separate issues that Recovery Audit Contractors (RACs) are targeting:

1. Excessive units of the initial E/M code 99291(Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes);

2. Critical care services billed on the same day as an emergency department (ED) visit; and

3. The unbundling of critical care.

And as if that’s not enough, critical care services also ranked in the top 20 on last year’s Medicare FFS Supplemental Improper Payment Data Report with a 19.1 percent improper payment rate, accounting for $184 million in improper payments — with claims data compiled and reviewed by Comprehensive Error Rate Testing (CERT) auditors.

With the heightened scrutiny, it’s vital for you to rein in unnecessary visits or make sure your documentation is bulletproof for those visits that are valid before your claims get pulled for medical review. Your best best is to pull a random sampling of charts and review them as an auditor would — then educate physicians on any findings that didn’t support the codes they reported.