Corporate Compliance

Note from Hugh

Medicare Insider, April 29, 2008

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This week, I would like to respond to the following e-mail we recently received from a reader:

    In a past hospital open door forum, Medicare representatives mentioned that hospitals should be following the CPT definition of critical care, specifically in that all of the services listed in the introduction the critical care section of CPT are to be bundled into the critical care code.  This is different from guidance CMS published in the April 7, 2000 Federal Register which stated that those services should be billed separately.

    CMS posted FAQ 8809 on their Web site which now states that we are to follow CPT guidelines for critical care. This makes no sense if you look at the details.  A level five ED visit (99285) has a national average reimbursement of $638. Critical care (99291) also has a national average reimbursement of $638, but is now supposed to include chest x-rays, vent management, blood gasses, etc?
    We would love to see Hugh comment on this.

I agree with this reader’s assessment. Under OPPS, CMS sets relative values (and ultimately payment rates) based on historical claim data. Until recently, many of the services that CMS now considers bundled into critical care were billed and paid separately under OPPS. That means that the current payment rates for critical care almost certainly do not include payment for the items that CMS now says are bundled into critical care.

This issue was raised with CMS representatives during two separate sessions at the Institute on Medicare and Medicaid Payment Issues held earlier this month in Baltimore.  I was present in both sessions.  My impression, unfortunately, was that CMS did not seem to be particularly troubled by this apparent inconsistency.

If CMS does address this issue before then, hospitals should be prepared to formally comment on this issue when CMS releases the OPPS proposed rule this summer.  Perhaps if CMS receives enough comments on this issue, they will consider making an appropriate adjustment to the critical care payment rate.

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