ED Coding and Reimbursement Alert

The Department of Health and Human Services Office of Inspector General (OIG) has released its work plan for fiscal year 2001. The work plan points out the areas the OIG will be looking at for strict enforcement, including areas it will audit to make sure the billing is correct. New to the work plan is a focus on the following:

Critical care codes (99291-99292): Vital to the emergency department (ED), critical care codes (99291, critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes; 99292, each additional 30 minutes) are a new target. OIG will examine the use of the two critical care codes that are only appropriately billed to Medicare if the patient is critically ill and requires constant attention by the physician. The OIG will be examining claim data to determine whether physicians are billing inappropriately for critical care.

You should have thorough documentation if you bill for critical care. Often one or more of the required descriptors or indications of the urgent and critical nature of the care are omitted from the physicians notes. For example, the amount of time the physician spends with the patient is important.

For more information on correctly coding for critical care see Case Study: Receive Optimum Payment for Critical Care in the October 2000 ED Coding Alert, page 77 and Rules for Determining Critical Care on the Basis of Time in the November 2000 ED Coding Alert, page 85.

Role of nonphysician practitioners: The OIG will identify the scope of services that nonphysician practitioners provide to Medicare patients and determine what potential vulnerabilities have emerged since the Balanced Budget Act of 1997.

ED coders need to be aware of the rules and regulations associated with nurse practitioners (NPs) and physician assistants (PAs) to be properly reimbursed for their services. PAs still need physician supervision, but in most states, NPs do not. The PA must bill if the patient has Medicare, however, with commercial payers the physician may be able to bill.

Note: For more information on nonphysician practitioners see Get Paid for NP and PA Services in the August 2000 ED Coding Alert, page 59.

Services and supplies incident to physicians services: While the OIG will be focusing on the conditions under which physicians bill incident to services and supplies, it is important to remember that incident to has been disallowed in the hospital setting for several years and thus the concept cannot be used in the ED. Physicians may bill for services provided by nurses, technicians and therapists as incident to their professional services in the office setting only.

Physicians need to be aware that they cannot bill incident to in the ED, and they need to make sure their coding/billing companies are aware of this and are not submitting for work that mid-level practitioners do under the physicians billing number, explains John Turner, MD, PhD, medical director for documentation and coding, healthcare financial services at TeamHealth, an ED staffing firm in Knoxville, Tenn.

Coders also need to be aware of two areas from the fiscal year 2000 work plan the OIG will continue to look at:

1. Physicians at teaching hospitals (PATH): OIG will verify that physician services provided in the teaching hospital setting comply with Medicare payment rules and that claims accurately reflect the level of service provided.

2. Reassignment of physician benefits: The practice of allowing physicians to reassign their billing numbers to clinics (which shifts the accountability and liability for billing abuses away from the physician and toward the clinic) will be evaluated.