General Surgery Coding Alert

Question: Can two physicians claim critical care for the same patient? I can find nothing in Medicare policy disallowing this, but I-m reluctant to report these services.


California Subscriber

Answer: You-re probably correct to be wary of reporting simultaneous critical care services (99291-99296) for the same patient for more than one physician. You-re right that CMS has no national policy saying you can't bill for two doctors performing critical care during the same hour. But CMS leaves this issue up to the carriers, and some of them have policies that specifically say only one doctor can provide critical care at a time. Example: Part B payer National Government Services (formerly known as Empire Medicare) has a policy that states: "Only one physician may bill for a given hour of critical care, even if more than one physician is providing care to a critically ill patient." Many carriers have similar language in their policies. Important: Before you bill, check both your local carrier's policies and frequently asked questions. So, what should you do if you-re not sure whether another doctor from another specialty may have provided critical care at the same time as your doctor? You can try contacting the coders of the other doctors seeing the patient. Or you could try to gain access to the patient's hospital records. Glitch: Coders may not know that more than one doctor was claiming the same critical care time until they submit their claims. In that case, usually the first claim submitted wins out, and the others receive denials. Appeal: If you can prove that "the hour Dr. X billed for critical care was not the same hour (and usually not the same reason) that Dr. Y billed," you can try appealing any denials you receive. In their local policies and FAQs, the carriers also caution that the physician must be physically available to the patient for the entire time you-re billing as critical care. Critical care can involve obtaining a history or discussing options with the patient's family, but the doctor must be available to rejoin the patient's side at any moment. Careful: Also, just providing emotional support to the patient's family doesn't count as "counseling and coordination of care," and thus can't be critical care. Clarification: Where the physician spends 15 minutes obtaining the patient history and another 15 minutes consoling the family, only the 15 minutes spent obtaining the history is reportable.-The physician could document the performance of both activities with the family but must constrain the billing time to only that time involved in taking the patient history. -- Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, [...]