Medicare Compliance & Reimbursement

If you don't meet these documentation requirements, you will not win appeal.

When you receive a denial from a payer for critical care services, you should not just give up on payment ...quot; nor should you automatically start the appeals process. Look back at the ED physician's op notes for the encounter, and then decide whether to appeal.

Benefit: At times, insurers deny legitimate critical care claims. However, you may also find that the denial was correct, in which case appealing is a waste of time and resources.

When a physician provides services that might be considered critical care, coders need to check documentation to discover:

• the patient's condition that necessitated critical care.
• how much time did the physician spent with the patient. Once you've answered these questions, you can determine whether your critical care claim was appropriate, experts say.

Before you code for critical care services using 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (... each additional 30 minutes [list separately in addition to code for primary service]), make sure the physician documented that the patient's condition warrants critical care.

Required: The physician needs to document that the patient is critically ill, which requires that the patient has at least one organ system that is failing and that the patient's life is in jeopardy.

CPT 2006 reports that the patient must have "a critical illness or injury [that] acutely impairs one or more vital organ systems" and requires the physician perform "decision-making of high complexity to assess, manipulate and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple organ system failure, or to prevent further deterioration."

According to Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver, ED physicians may treat critically ill patients who:

• are having a heart attack.
• ingested some type of poison.
• overdosed on some type of drug(s). "Critical care also includes trauma care for patients with severe injuries," Hammer says. This includes patients who have:

• a gunshot or stab wound.
• extensive injuries from an automobile accident.
• severe burns.
• head trauma due to a fall with a loss of consciousness. Caution: A patient does not have to be in the intensive care unit (ICU) to be critically ill, and similarly, not every patient in ICU is critically ill, says Pierre Edde, MD, director of the sleep and respiratory services at Uniontown Hospital in Pennsylvania and founder of www.PCSbilling.com.

The key is the "high probability of imminent or life-threatening deterioration in the patient's condition," Edde says. Time Is a Critical Factor Critical [...]