Corporate Compliance

Note: Application of critical care Correct Coding Initiative (CCI) edits to hospitals

Medicare Insider, March 3, 2009

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Editor’s note: Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc., is the author of this week’s note from the instructor.

Effective January 1, 2009, the CCI edits for evaluation and management (E&M), including critical care, apply to hospitals. Two prior-existing frequently asked questions (FAQ) have been updated to reflect these changes. The updated FAQs are FAQ 8813 and FAQ 2392. Prior to January 1, 2009, not all CCI edits that applied to physician services also applied to comparable hospital services. In particular, those CCI edits that applied to physician E&M services (including critical care) were not incorporated into the Outpatient Code Editor (OCE) for application to hospital E&M services. 

For a number of years, coding guidelines for critical care set out in the CPT Manual stated that certain services (e.g., interpretation of cardiac output measurements, chest X-rays, pulse oximetry, etc.) were included in reporting critical care when performed during the critical period by the physician(s) providing critical care. That is, they were not separately billable when performed during the period of critical care.

Because the CCI edits implementing these bundling rules had not been incorporated into the OCE, some hospitals apparently believed that the critical care bundling rules did not apply to hospitals. Acting on that belief, some hospitals may have billed those bundled services performed during the period of critical care separately, rather than rolling the related charges into the charge line for critical care. In December 2007, CMS issued FAQ 8809 to clarify its position regarding hospitals’ ability to bill those services included in the critical care bundling rules. In FAQ 8809, CMS stated that “Hospitals must follow the CPT instructions related to CPT code 99291 [critical care]. Any services that CPT indicates are included in the reporting of CPT code 99291 should not be billed separately by the hospital.” 

CMS made its position increasingly clear during several subsequent Hospital Open Door Forum calls, as well as additional CMS pronouncements. Hospitals are to follow the bundling rules for critical care set out in the CPT manual for those services that are actually provided during the period of critical care. The incorporation of the E&M CCI edits into the OCE simply implements CMS’ prior-existing policy. To the extent that those services are provided outside the period of critical care, however, they are potentially separately payable. 

Going forward, it is important for hospitals to assure that they bill those services that are designated as “included” in CPT code 99291 correctly. To the extent that those services are provided during the period of critical care, the charges associated with them should be rolled up into the charge line for critical care. They should not be billed as separate line items. On the other hand, if they are provided on that same date of service but outside the period of critical care, they are potentially billable as separate line items.



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