Pulmonology Coding Alert

Plus: Documentation must include specific details to report critical care.

Do your pulmonologists document as thoroughly as they should when billing critical care visits? And are they justified in appending modifiers to these claims?

That’s what auditors sought to determine as part of a new comparative billing report (CBR) compiled by RELI Group, Inc., which CMS contracts to develop, produce, and distribute CBRs. The firm undertook an investigation after learning that critical care services had an improper payment rate of 9 percent in 2019, representing $18 million in projected improper payments, said RELI’s Annie Barnaby during a Nov. 5, 2020 presentation on the topic. Because so many pulmonologists have critical care specializations, it’s important to get a handle on what’s causing these errors.

“Within that error rate, there is a 31 percent improper payment rate due to insufficient documentation, and a 68.5 percent improper payment rate due to incorrect coding,” Barnaby said during the session. “Code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) alone carries an improper payment rate of 18.3 percent, which represents over $74 million in project improper payments just for that code.”

Ensure That Documentation Includes These Elements

To ensure that your critical care documentation meets the government’s standards and is not subject to repayments, always check that you have recorded the following in the medical record, Barnaby said:

• Medical necessity
• Proof that the patient was critically ill
• Demonstration of high complexity medical decision making
• Notes on the time spent in critical care so the assigned codes can be supported

In addition, she noted, “the use of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) should be reviewed and confirmed. Is there a significant, separately identifiable evaluation and management service that is documented correctly, that calls for the use of the modifier 25? We want to be sure that all of these documentation and services guidelines are met when we’re using critical care codes and modifier 25.”

To determine what types of mistakes critical care providers are making, RELI reviewed claims data from 2019 to 2020 showing how 91,000 providers submitted these types of claims. The reviewers looked at the following parameters as part of the review, Barnaby said:

• Percentage of services submitted with modifier 25
• Average number of visits per beneficiary
• Average allowed charges per beneficiary

Check out the breakdown of how critical care providers fared during the analysis.

Metric 1: Percentage of Services Submitted With Modifier 25

To calculate this, RELI divided by the number of critical care services submitted with modifier 25 by total critical care claims. The national average is 11.9 percent, Barnaby noted. However, providers in some states far exceeded that, with the highest being in Alaska at 31.87 percent of critical care claims submitted with modifier 25. The lowest rate was in Puerto Rico at 5.06 percent, followed by Illinois at 7.92 percent.

To determine where you stand, calculate which percentage of your critical care services are reported with modifier 25, and then compare that against your state’s average (which is in RELI’s “National and State Data” sheet at https://cbr.cbrpepper.org/About-CBR/CBR-202009) and the national average of 11.9 percent.

Best practice: While some services (such as pulse oximetry and vent management) are included in the codes for critical care, some other services are separately billable if you append modifier 25. However, you must maintain appropriate documentation to demonstrate the medical necessity showing the separate nature of the E/M versus the procedure.

Example: The physician provides 47 minutes of critical care and spends an additional 34 minutes performing CPR and endotracheal intubation.

On this claim, you should report 92950 (Cardiopulmonary resuscitation (eg, in cardiac arrest)) for the CPR and 31500 (Intubation, endotracheal, emergency procedure) for the intubation. Then, report 99291-25 for the critical care.

Ensure that your documentation clearly demonstrates the medical necessity for the CPR and the intubation, along with notes about the details of every service performed. Be clear that the critical care time excludes the time spent performing these other services, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

Metric 2: Average Number of Visits Per Beneficiary

The next variable measured how many total critical care visits patients had — but keep in mind, this only applied to patients who had at least one critical care visit, so the pool of beneficiaries included in the metric does not include those who never had critical care services.

“For this metric, number of visits means a distinct date of service,” Barnaby said. To arrive at this number, reviewers divide the number of unique critical care visits by the total number of unique beneficiaries who had a critical care service. The national average is 1.49, Barnaby said.

However, in some regions, providers exceeded the average significantly. For instance, the average number of critical care visits in Puerto Rico was 2.75, while in California it was 1.87. On the opposite end of the spectrum, beneficiaries in Wyoming  only had an average number of critical care visits of 1.17 per patient, the results indicated.

Metric 3: Average Allowed Charges Per Patient

To calculate the average allowed charges, reviewers divided the sum of the total allowed charges for critical care services by the count of unique beneficiaries who had a critical care service. The national average in this category is $451.34, although there were some states that were significantly different. In California, that number hit $574.96, while Wyoming was home to the lowest average charge per patient, at $321.79.

Best practice: Barnaby reminded practices that critical care cannot be reported unless the patient meets the standard of critical care as defined by the AMA. “The CPT^® book defines critical care services as ‘the direct delivery by a physician(s) or other qualified health care professional 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,’” Barnaby said. “So, when we’re talking about critical care, about these codes, we are talking about patients who are very ill and in need of advanced care.”