ED Coding and Reimbursement Alert

Hot spot: Prepayment edits of evaluation and management (E/M) code 99291.

Medicare auditors are starting to look more closely at claims for code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) with a special focus on the documentation of time spent. Read on to learn the latest.

Peruse some of the MAC websites, and you will find notices like this one from First Coast Service Options, says Todd Thomas, CPC, CCS-P, President of ERcoder, Inc. in Edmond, OK.

Recent data analysis pertaining to critical care services has identified that First Coast is at a high risk for claim payment error. The error is based on potential overutilization and/or abuse of code 99291. In response to the high risk for payment error, First Coast has implemented two prepayment review edits for claims submitted on or after February 18, 2013, which apply to all providers within First Coast’s Florida jurisdiction. Below are summaries of how these edits will be applied:

·         A 100% prepayment review edit will be applied to critical care services provided outside the following places of service: 21 Hospital, 22 Outpatient Hospital, 23 Emergency Room.

·         A prepayment edit will be applied to all utilization outlier claims identified.

The first bullet is not of great concern to the ED, but the second bullet could be trouble.

Best bet: Review your local payer policy for exact language on what’s required for documenting critical care time.

In summary, though Medicare is rarely detailed and directive, relying solely on a generic attestation may be increasingly risky. Patient specific information serves to support the physician services provided to these very high acuity patients, Thomas suggests.