Health Information Management

Q/A: 2011 Critical care coding changes

APCs Insider, December 3, 2010

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Q: Did CMS make any more changes to critical care coding for 2011?

A: CMS is making a change to processing claims for 2011 based on a change in CPT® guidelines. The AMA included new introductory notes that explain how to report professional services and facility/technical services.

The notes state that "for reporting by professionals, the following services are included in critical care when performed during the critical period by the physician(s) providing critical care" and lists the services and some CPT codes. The AMA further states in the notes that "[f]acilities may report the above services separately."

CMS notes in the 2011 OPPS final rule that payment for critical care services has been included the listed services for several years because it expects hospitals to follow CPT guidelines. CMS continues to state that it expects hospitals to follow CPT guidelines and that beginning in CY 2011 hospitals will "begin reporting all of the ancillary services and their associated charges separately when they are provided in conjunction with critical care."

CMS will institute claims processing edits to conditionally package payment for ancillary services reported on the same date of service as critical care. This will avoid overpayment because payment rates are based on claims data for CY 2009, when hospitals would have reported charges for ancillary services as part of the charge for the critical care service. The ancillary services as defined in the CPT guidelines will be assigned to status indicator Q3. This will allow packaging when ancillary services are reported with critical care but provide separate payment when they are reported outside the critical care scenario.

Editor’s note: Denise Williams, RN, CPC-H, Director of Revenue Integrity Services for Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.


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