Medicare Compliance & Reimbursement

Location cuts both ways.

A recent clarification on critical care services from the Centers for Medicare and Medicaid Services (CMS) should come as a major relief to your physicians as well a boost to reimbursement.

Scenario: Your physician performs CPR for a non-responsive patient in the observation care unit of the hospital, where he attends to the patient for 30 minutes, and the patient is later moved to the ICU, where your physician sees her for another 75 minutes evaluating her need for a mechanical ventilator, feeding tube and accompanying sedation while she stabilizes. Your physician bills for 70 minutes of critical care services, right? Wrong.

Myth: Although many physicians believe they can only report critical care services for patients who are in the hospital’s intensive care or critical care unit, that longstanding belief is a myth.

Reality: CMS defines critical care as “a physician’s direct delivery of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.” Therefore, if your physician performs critical care services for a patient in shock, renal failure, circulatory failure, or other life-threatening conditions, you should be able to report critical care services.

In black and white: CMS addresses the confusion in MLN Matters article MM5993, noting, “While critical care is usually given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit or the emergency department, payment may also be made for critical care services that you provide in any location as long as this care meets the critical care definition.”

In our example above, the physician providing the critical care services would report one unit of 99291 (Evaluation and management of the critically ill or critically injured patient, first 30 to 74 minutes) and one unit of 99292 (…each additional 30 minutes…) to cover his 105 minutes with the patient.

Remember that your physician must be treating vital organ failure and preventing further deterioration during his critical care services to be considered medically necessary. “Therefore, delivering critical care in a moment of crisis, or upon being called to the patient’s bedside emergently, is not the only requirement for providing critical care service,” CMS says.

To count your physician’s critical care time, add the time he spent giving full attention to the critically ill patient and not any time providing care to other patients.

Remember the Other Side of the Coin

Just as you can report critical care services for any location if the patient meets the criteria, the opposite is true as well. If a patient is in the critical care unit and your physician treats her for a non-life-threatening condition, you cannot report critical care services. For instance, if a patient is in kidney and lung distress due to Goodpasture’s Syndrome (446.21) and your dermatologist treats the patient for an accompanying topical rash in the critical care unit, the dermatologist cannot report the critical care codes.

Resource: To read CMS’s MLN Matters article on this topic, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5993.pdf.