Medicare Compliance & Reimbursement

Patient must really be critically ill.

Myth: Two providers can't bill for critical care for the same patient during the same time period.
 
Reality: Nothing in the Centers for Medicare & Medicaid Services (CMS) Manual, or other sources, says two or more providers can't bill for concurrent critical care, says Betsy Nicoletti with Medical Practice Consulting in Springfield, VT.

You should make sure to consult your local carrier's policies. Some carriers do require that providers must be from different specialties to provide critical care at the same time, says Nicoletti.

Often, physicians from different specialties, such as nephrology, cardiology and pulmonology, will treat the same patient at the same time, notes Nicoletti. And if the patient is critically ill and requires life-saving treatment, then they all should be able to bill.

Some multi-specialty practices may be hesitant to bill for critical care services by two different physicians at once, Nicoletti notes. But if you downgrade one of the two doctors' services to a subsequent visit code, then you could be losing out on your rightful reimbursement.

Caution: You should make sure the doctors are providing different services, says Maggie Mac, a consultant with Pershing Yoakley & Co. in Clearwater, FL. If two or three doctors all say they did exactly the same thing, it won't hold up in an audit.

For example: One doctor could be reviewing tests and recommendations and checking the patient's vital signs. A second doctor could be examining the patient and reviewing the patients' ongoing care and "medical management," says Mac.

Or if the patient has multiple problems, such as diabetes, hypertension and heart failure, different physicians could be providing critical care in different areas, she adds.

Bottom line: Your doctors must be providing critical care to critically ill patients. The fact that a patient is in the intensive care unit (ICU) does not automatically qualify any treatment as critical care, Mac says. The physician's services have to be crucial for maintaining the patient's life and preventing "loss of body function or organ-system failure."