ED Coding and Reimbursement Alert

A recent Office of Inspector General (OIG) study reported that HCFAs concerns about physicians not properly using critical care codes are unwarranted.

The OIG study was conducted in response to changes made to critical care code definitions in 1999 and 2001. HCFA expressed concerns that removing unstable from the critical care requirements, which were reworded to read high probability of survival is jeopardized, would induce ED practitioners and coders to bill critical care more heavily.

To prevent overbilling of such services, HCFA decreased the relative value units for 99291-99292 in 2000. The study revealed, however, that emergency medicine accounted for only $24.6 million of the $353 million of total critical care claims submitted.

The report also noted that Medicare is not mistakenly paying separately for services that should have been bundled into critical care codes. The OIG estimated that only 2,900 services, totaling $51,800 in improper payments, should have been bundled into the critical care payment. The agency also reports that questionable payments for services, based on an absence of first hour claims, have dropped by 75 percent since 1998.