Health Information Management

Submitting 2009 facility critical care claims

APCs Insider, December 26, 2008

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Q. Can you comment on facility critical care and how to submit claims for 2009?


A. From the end of December 2007 through 2008, CMS’ position regarding facility claims and the submission of critical care services with CPT code 99291 (critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 minutes) puzzled hospitals, FIs, and MACs. The question has been whether the hospital follows the CPT instructional guidelines within the critical care section of the CPT manual and those services which are part of the guidelines.


The 2009 OPPS final rule, below, clarifies CMS’ position, which in turn means sweeping operational challenges for hospitals:


Hospitals should separately report all HCPCS codes in accordance with correct coding principles, CPT code descriptions, and any additional CMS guidance, when available. Specifically with respect to CPT code 99291, hospitals must follow the CPT instructions related to reporting that CPT code. Any services that CPT indicates are included in the reporting of CPT code 99291 should not be billed separately by the hospital. In establishing payment rates for visits, CMS packages the costs of certain items and services separately reported by HCPCS codes into payment for visits according to the standard OPPS methodology for packaging costs.


Consistent with past input we have received from many hospitals, hospital associations, the APC Panel, and others, we will continue to utilize CPT codes for reporting services under the OPPS whenever possible to minimize hospitals’ reporting burden. If the AMA were to create facility-specific CPT codes for reporting visits provided in HOPDs, we would certainly consider such codes for OPPS use.

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