Health Information Management

Q/A: Critical care and NCCI edits

APCs Insider, February 25, 2011

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Q: A note in the 2011 CPT® update states that facilities may now bill separately for services included in the definition of critical care. Unfortunately, it appears that the National Correct Coding Initiative (NCCI) edits were not updated to reflect this information in January. As a result, we are getting NCCI edits whenever we report one of the codes listed in the instructions on the claim along with 99291 (critical care, first hour) and 99292 (critical care, each additional 30 minutes). Is appending modifier -59 (separate procedural service) based on CPT’s instructions appropriate?

A: Reporting the service separately is appropriate. However, append modifier -59 only if the service is not performed during the critical care event. The AMA has said that bundling procedures into critical care is for professional services only and that facility providers should report them separately.

However, CMS has instituted edits to insure that these services continue to be packaged. Appending modifier -59 tells CMS that the service was separate and distinct from the critical care service, and according to Transmittal 2141, performed during a different encounter on the same date of service as critical care. You may and should report the line items separately to be in compliance with CPT guidelines, but don’t append modifier -59 unless separate and distinct from the critical care episode. Information from Transmittal 2141, CR 7271, published January 24, 2011, follows:

5. Reporting Hospital Critical Care Services Under the OPPS 

For CY 2010 and in prior years, the AMA CPT Editorial Panel has defined critical care CPT codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service)) to include a wide range of ancillary services such as electrocardiograms, chest X-rays and pulse oximetry.

As stated in manual instruction, hospitals should report in accordance with CPT guidance unless CMS instructs otherwise. For critical care in particular, CMS has instructed hospitals that any services that the CPT Editorial Panel indicates are included in the reporting of CPT code 99291 (including those services that would otherwise be reported by and paid to hospitals using any of the CPT codes specified by the CPT Editorial Panel) should not be billed separately. Instead, hospitals should report charges for any services provided as part of the critical care services.

Beginning January 1, 2011, under revised AMA CPT Editorial Panel guidance, hospitals that report in accordance with the CPT guidelines will begin reporting all of the ancillary services and their associated charges separately when they are provided in conjunction with critical care. CMS will continue to recognize the existing CPT codes for critical care services and is establishing a payment rate based on its historical data, into which the cost of the ancillary services is intrinsically packaged. The I/OCE logic will conditionally package payment for the ancillary services that are reported on the same date of service as critical care services in order to avoid overpayment. The payment status of the ancillary services will not change when they are not provided in conjunction with critical care services. Hospitals may use HCPCS modifier -59 to indicate when an ancillary procedure or service is distinct or independent from critical care when performed on the same day but in a different encounter.

CMS is updating Pub. 100-04, Medicare Claims Processing Manual, chapter 4, section 160.1, to reflect the revised critical care reporting guidelines and OPPS payment policy.

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

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