Medicare Compliance & Reimbursement

Tip: Both the illness and treatment must fit into Medicare’s parameters.

With critical care services, it’s important to pick the code that fits the circumstances and is easily backed up by the documentation. Without the medical cause-and-effect combination supported by the agency’s nuanced guidelines, your claims may head to the audit zone.

“Providing medical care to a critically ill patient should not be automatically deemed to be a critical care service for the sole reason that the patient is critically ill or injured,” cautions CMS in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.12.

For that reason, it’s vital that practices keep in line with CMS specifics to protect claims from being pulled for review. Some examples of potential critical care scenarios include, but are not limited to, patients suffering from:

• respiratory failure,
• cardiac failure,
• kidney failure,
• metabolic failure,
• brain injury,
• major traumas, or
• a combination of the above or with other comorbidities.

In a nutshell: The criteria that say the patient has to be critically ill or injured such that there is a threat to life and limb applies to all of the critical care codes, explains Donelle Holle, RN, President of Peds Coding Inc, and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Reference: For a more in-depth look at the Medicare Claims Processing Manual and the rules for billing critical care services, visit www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf.