Corporate Compliance

Note from Hugh

Medicare Insider, February 26, 2008

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In the February 12 edition of the Medicare Weekly Update, I commented on CMS's recent FAQ relating to the application of the CPT critical care bundling guidelines to hospitals. I noted that, as announced during the January 31 Hospital Open Door Forum conference call, CMS is now taking the position that hospitals may not separately bill for services identified by the CPT Manual as included in critical care when the additional services were provided in conjunction with critical care services.

Several readers have contacted HCPro regarding this issue. In general, our readers seem interested in learning whether other hospitals have operationalized the critical care bundling guidelines. One reader told us bluntly that her hospital has "not changed our billing of critical care."

While one could certainly complain about the way CMS implemented this change (i.e., through a FAQ and the Hospital Open Door Forum conference call, rather than through some more formal means), it seems clear to me that CMS expects hospitals apply the critical care bundling guidelines to all outpatient claims involving critical care services. Among other things, this means that hospitals should have reconfigured their internal "claims scrubbers" to apply the National Correct Coding Initiative (NCCI) edits to all critical care claims, even though Medicare's Outpatient Code Editor does not apply the NCCI Evaluation and Management Services edits to hospital claims.

If your hospital has not yet made this change, you should discuss this issue with your compliance department and/or legal counsel. It would not surprise me if the enforcement authorities take the position that a hospital's failure to "edit out" services included in the critical care bundling edits constitutes improper billing subject to sanctions, including the Civil False Claims Act.



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