Wiki Can 99291 and 99292 Critical Care be reported separately for same patient same day by different physicians of same specialty?

[she803]

Good evening
CPT 99292 was denied due to cotiviti issue, that claim was billed without a primary code 99291. The previous claim CPT 99291 was reported with different physician of same specialty on same service date

However, in the CMS Manual 30.6.12.8 indicates the following:
"When one practitioner begins furnishing the initial critical care service, but does not meet the time required to report CPT code 99291, another practitioner in the same specialty and group can continue to deliver critical care to the same patient on the same date.
The total time spent by the practitioners is aggregated to meet the time requirement to bill CPT code 99291. Once the cumulative required critical care service time is met to report CPT code 99291, CPT code 99292 can only be reported by a practitioner in the same specialty and group when an additional 30 minutes of critical care services have been furnished to the same patient on the same date (74 minutes + 30 minutes = 104 total minutes)."

Unless I've misread the above policy, doesn't this mean the claim billed for 99292 from Dr. B (pulmonary) can also be billed/reported separately CPT 99291 from Dr. A (pulmonary)?

If so, I do not understand why it was denied.

Thank you for your assistance!

 

[bill2doc]

I've not seen a 99292 alone get paid. Are these doc's in the same group? If in same group the time would be added together and one NPI billed. If separate group (two independent physicians) Then each should be able to bill for 1 unit of 99291 if meet the qualifications of 30-74 min

 

[she803]

Totally appreciate your assistance--thank you very much!

The 2 physicians work for the same group and same specialty as GI specialists.

The GI specialists Dr. "A" billed 99291 then Dr. "B" billed 99292 on same service date for the same patient.

So I thought this case applies to the above guidelines, "Once the cumulative required critical care service time is met to report CPT code 99291, CPT code 99292 can only be reported by a practitioner in the same specialty and group when an additional 30 minutes of critical care services have been furnished to the same patient on the same date (74 minutes + 30 minutes = 104 total minutes)."

 

[CBLENNIE]

I work for an insurance carrier, and we would allow the 99292 to be submitted under Dr. B. since he and Dr. A. are of the same specialty in the same provider group. However, the claim may be denied when it is initially processed because of our claims editing software not being able to apply the logic that Dr. A. and Dr. B. are essentially a single provider for billing purposes, the software simply looks at the patient's claim history and finds that the add-on code was billed without a claim for the primary procedure billed by Dr. B and denies the 99292.

These claims often process through our system and are denied without a human touching the claim, so allowing benefits for 99292 is more likely to happen as the result of an inquiry from the provider's office about the denial or through a formal appeal.

Is Cotiviti acting as a third-party vendor performing audits on behalf of your carrier, or are they processing claims on behalf of your carrier? If they are acting as a third-party auditor on behalf of your carrier you should have received their audit findings in a letter and in theory the letter should include information regarding how to appeal their finding. If you cannot get Cotiviti to overturn their denial of the 99292 try appealing directly to the insurance carrier. If that fails, contact your provider contracting/relations representative at the insurance carrier and let them know about the issue. Try to provide as many examples claims where Cotiviti has denied 99292 in the situations like you are having and ask them to take the issue up with Cotiviti. Cotiviti should be able to modify their algorithm that is identifying these claims to either allow these codes billed by separate providers in the same group of the same specialty or they can put logic in place that requires a human analyst to determine if the edit is appropriate or not before sending the denial recommendation to the insurance carrier to deny the 99292.

I don't know how it works for other insurance carriers that contract with companies like Cotiviti handle their post-payment claims audits, but our organization does not have to accept the vendors audit findings as always correct/valid. I work as a Claims Investigative Examiner and my job is to work these types of vendor audits and I am responsible for validating that their audit finding is correct per coding guidelines and if the vendor is wrong, I dispute their finding and will not adjust the claim to apply the incorrect edit.

If you have any additional questions about how to appeal this with Cotiviti or directly with insurance carrier, please don't hesitate to reach out to me, I'm happy to be off assistance in any way I can. I'm out here try to show the coding community that not all insurance carriers are evil and some of us want to be partners with the provider community working to make certain our members/your patients receive the best care at affordable prices.

 

[natashalage]

What a Wonderful response, Cblennie! I am not the one who asked the question but I have already learned a lot from this forum. Thank you very much for your comprehensive response, your time in explaining it to us and your help. That's the Team work!

 

[CBLENNIE]

What a Wonderful response, Cblennie! I am not the one who asked the question but I have already learned a lot from this forum. Thank you very much for your comprehensive response, your time in explaining it to us and your help. That's the Team work!

I am happy to help anyone who is looking for insight into how insurance carriers process claims if I can. I am willing to try and answer any questions anyone has about the insurance carrier side of things, just send me a DM via the AAPC website and I will try to assist if possible.

We are all in this together and we need to collaborate more and see each other as partners not adversaries.

 

[kfwarner79@gmail.com]

Totally appreciate your assistance--thank you very much!

The 2 physicians work for the same group and same specialty as GI specialists.

The GI specialists Dr. "A" billed 99291 then Dr. "B" billed 99292 on same service date for the same patient.

So I thought this case applies to the above guidelines, "Once the cumulative required critical care service time is met to report CPT code 99291, CPT code 99292 can only be reported by a practitioner in the same specialty and group when an additional 30 minutes of critical care services have been furnished to the same patient on the same date (74 minutes + 30 minutes = 104 total minutes)."

Wouldn't it be the same as 2 surgeons working together in the or and billing out separately ? They're working together in the same capacity.

 

[shirleyharris]

I work for an insurance carrier, and we would allow the 99292 to be submitted under Dr. B. since he and Dr. A. are of the same specialty in the same provider group. However, the claim may be denied when it is initially processed because of our claims editing software not being able to apply the logic that Dr. A. and Dr. B. are essentially a single provider for billing purposes, the software simply looks at the patient's claim history and finds that the add-on code was billed without a claim for the primary procedure billed by Dr. B and denies the 99292.

These claims often process through our system and are denied without a human touching the claim, so allowing benefits for 99292 is more likely to happen as the result of an inquiry from the provider's office about the denial or through a formal appeal.

Is Cotiviti acting as a third-party vendor performing audits on behalf of your carrier, or are they processing claims on behalf of your carrier? If they are acting as a third-party auditor on behalf of your carrier you should have received their audit findings in a letter and in theory the letter should include information regarding how to appeal their finding. If you cannot get Cotiviti to overturn their denial of the 99292 try appealing directly to the insurance carrier. If that fails, contact your provider contracting/relations representative at the insurance carrier and let them know about the issue. Try to provide as many examples claims where Cotiviti has denied 99292 in the situations like you are having and ask them to take the issue up with Cotiviti. Cotiviti should be able to modify their algorithm that is identifying these claims to either allow these codes billed by separate providers in the same group of the same specialty or they can put logic in place that requires a human analyst to determine if the edit is appropriate or not before sending the denial recommendation to the insurance carrier to deny the 99292.

I don't know how it works for other insurance carriers that contract with companies like Cotiviti handle their post-payment claims audits, but our organization does not have to accept the vendors audit findings as always correct/valid. I work as a Claims Investigative Examiner and my job is to work these types of vendor audits and I am responsible for validating that their audit finding is correct per coding guidelines and if the vendor is wrong, I dispute their finding and will not adjust the claim to apply the incorrect edit.

If you have any additional questions about how to appeal this with Cotiviti or directly with insurance carrier, please don't hesitate to reach out to me, I'm happy to be off assistance in any way I can. I'm out here try to show the coding community that not all insurance carriers are evil and some of us want to be partners with the provider community working to make certain our members/your patients receive the best care at affordable prices.

Excellent response; thank you so much!! I would just add that if Dr. A billed 99291 + 99292, Dr. B would not be paid for an additional 99292. We discovered that most payors want 99292 billed with units, rather than on separate lines, so the second 99292 cannot be billed out on a separate claim. We add Dr. B's 99292 to Dr. A's claim and billed 99292 with 2 units.