Wiki Medical Necessity for Critical Care

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clbarry8033

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We have been outsourcing one physician's Intensivist charges for several years. Just recently, we have been getting documentation returned and down coded stating:

"Documentation does not support medical necessity for critical care. Provider's physical exam states "Patient in no acute distress.""

This issue has never been brought up until the last couple of weeks.

There has been no change in the way the provider documents, the illnesses/description of treatment are appropriate to support critical care, and he always documents total critical care time spent. Everything but this statement on the exam meets the guidelines for providing medically necessary critical care services.

My question for auditors is this:

I have seen publications that mention this certain statement may not support critical care. Is this statement alone enough to automatically disqualify his services as critical care? Obviously he sees these as critical care services, or he wouldn't be documenting total critical care time. I am just a CPC, and don't feel myself, nor any other CPC, would be qualified to contradict a clinically trained physician's opinion when everything but this statement supports critical care. Isn't this a determination that should be left to trained auditors?

There are definitely circumstances where the lack of support for critical care is obvious, and could be easily identified by a regular CPC, but I feel this is not the case here.

Any help/opinions would be greatly appreciated.

Thanks!

Chelsea Barry, CPC
 
If the patient is in no acute distress then it is easy to believe that critical care services were not necessary. You may have the documentation to support that the services were delivered, however stating that the patient was in no acute distress, demonstrates that critical care was not needed. You need the patient diagnosis to support the service provided. Clearly the care provided exceeded that which was needed.
 
The associated diagnoses I've seen these comments on include:

Acute respiratory failure with hypercapnia and hypoxemia
Syncope with acute upper GI bleed and associated severe acute blood loss anemia and thrombocytopenia
Severe sepsis due to UTI with elevated lactate
DKA

I think all of these would certainly justify the need for critical care.

Would it be different if the provider had added a medical necessity statement of the organ systems at risk?

Thanks again for your help. Just want to be sure before explaining this to the provider, who will already be angry about people questioning his clinical opinion. :)
 
clbarry8033 said:
We have been outsourcing one physician's Intensivist charges for several years. Just recently, we have been getting documentation returned and down coded stating:

"Documentation does not support medical necessity for critical care. Provider's physical exam states "Patient in no acute distress.""

This issue has never been brought up until the last couple of weeks.

There has been no change in the way the provider documents, the illnesses/description of treatment are appropriate to support critical care, and he always documents total critical care time spent. Everything but this statement on the exam meets the guidelines for providing medically necessary critical care services.

My question for auditors is this:

I have seen publications that mention this certain statement may not support critical care. Is this statement alone enough to automatically disqualify his services as critical care? Obviously he sees these as critical care services, or he wouldn't be documenting total critical care time. I am just a CPC, and don't feel myself, nor any other CPC, would be qualified to contradict a clinically trained physician's opinion when everything but this statement supports critical care. Isn't this a determination that should be left to trained auditors?

There are definitely circumstances where the lack of support for critical care is obvious, and could be easily identified by a regular CPC, but I feel this is not the case here.

Any help/opinions would be greatly appreciated.

Thanks!

Chelsea Barry, CPC
Click to expand...

I suspect the phrase "in no acute distress" which reflects the patient's general appearance as an examination element is being misconstrued to mean the patient is not critically ill or injured. I have seen this in publications (usually by non-physicians) as well. CPT defines a critical illness or injury as an illness or injury that 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. This is especially important in considering codes for neonatal and pediatric critical care where evaluations are repeated throughout each day. I would definitely consult an experienced auditor or physician for advice on these cases before using this statement alone to rule-out critical care.
 
Nad

NAD is one of those age old acronyms that many providers habitually document. I agree with others that it shouldn't disqualify CC or high level E&Ms for that matter. And I agree the provider most likely is referring to the general appearance of the patient at the moment they are examining them. It still doesn't look good with CC upon outside audit. Might be an education issue for the provider to let go of an old habit. Kind of like the few (in AARP demographic like me) who still use SOAP.

Jim
 
My first thought is why is he stating this with all of these serious diagnoses? Is he using a macro exam and not editing it? That's cause for pause in an auditors eyes. I would definitely bring it to the providers attention.
 
JADAS said:
CC TIME of 80 mins.how should it be billed?

99291 only or 99291 and 99292 x 1
Click to expand...

There's a handy chart in the CPT book. My CPC trainer advise me to put a note by the critical care codes in my book to use the chart. This isn't one of those circumstances where you need to spend 50% of the time in the add-on to report.

75-104min you can bill 99291 x1 & 99292 x1.
 
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"This isn't one of those circumstances where you need to spend 50% of the time in the add-on to report. "
what do you mean by that?
WHAT ABOUT THE 15 MINUTES THRESHOLD
 
Last edited:
JADAS said:
"This isn't one of those circumstances where you need to spend 50% of the time in the add-on to report. "
what do you mean by that?
WHAT ABOUT THE 15 MINUTES THRESHOLD
Click to expand...

This code you only need to go 1 min over 74 minutes in order to bill for the 30 extra minutes so you get a 29 minutes bonus. For some codes out there (for instance prolonged service), you need to spend at least 50% or 15 of the 30 minutes to be able to round up. Its too confusing which codes you get to round up and which ones you don't so AMA added chart to make it easier to determine. Another example is the rule of 8's in PT and Anesthesia where if you don't spend 8 min of the 15 specified in the code you cant report it.
 
Billing 99291 and 99292 two different providers

Hi, please help with answering how to avoid denials when claim must be billed with parent code 99291 on the same hcfa form or invoice. This is not possible when there are two different providers. Dr. A is billing parent code 99291 and dr. B is billing add on code 99292. Any suggestions on how to avoid these denials?
 
NANASIA said:
Hi, please help with answering how to avoid denials when claim must be billed with parent code 99291 on the same hcfa form or invoice. This is not possible when there are two different providers. Dr. A is billing parent code 99291 and dr. B is billing add on code 99292. Any suggestions on how to avoid these denials?
Click to expand...

Only one physician may bill for critical care during any one single period of time, even if more than one physician is providing care
 
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