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Medicare Compliance & Reimbursement

PART B:

Check With Your Local Carrier For Concurrent Critical-Care Coverage

Published on Mon Apr 23, 2007

2 doctors, simultaneous critical care could lead to denials.

Myth: There's no national policy forbidding concurrent critical care, so you should just go ahead and bill for it.

Reality: It's true that the Centers for Medicare & Medicaid Services 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: 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. "I certainly didn't find it on every carrier," says Suzan Hvizdash, physician educator with the UPMC-Department of Surgery in Pittsburgh, PA and former AAPC Advisory Board member.

Important: Before you bill, check both your local carrier's policies and frequently asked questions (FAQs), Hvizdash stresses. Don't neglect to double check on the local level.

What should you do if you're not sure whether another doctor from another speciality has provided critical care at the same time as your doctor? You can try contacting the coders of the other doctors seeing the patient, Hvizdash suggests. Or you could try to gain access to the patient's hospital records, experts add.

Glitch: Coders may not know that more than one doctor was claiming the same critical care time until they submit their claims, Hvizdash adds. 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, Hvizdash advises.

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 able 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, Hvizdash notes.

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," notes Michael Miscoe, president of Practice Masters in Central City, PA. "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."

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