Health Information Management

Q/A: Billing chest x-ray and venipuncture separately from critical care

APCs Insider, December 16, 2011

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Q: Our MAC audited some of our critical care accounts and denied charges for chest x-ray and venipuncture because they were not performed during a separate encounter. We reported these services with modifier -59 (distinct procedural service) to show that we performed them after the critical care episode ended, but the MAC still denied them. We want to appeal the denials, but aren’t sure why the MAC denied them the first time. We think there may be a problem with our MAC’s interpretation of CMS guidance. Can you offer any insight?

A: For CY 2011, in response to the AMA’s updated guidelines regarding facility reporting of services included in critical care, CMS maintained its stance that payment for these services would remain packaged unless a facility provides these services during a separate encounter.

In response to the instructional change, CMS updated the I/OCE to ensure that the payment for these services continued to be packaged into the payment for CPT® 99291 (critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 minutes). Critical care in the ED is reported to reflect the level of care provided to a patient for that ED visit/encounter. CMS published the following guidance in the January 2011 update to OPPS (Transmittal 2141):

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.

Separate encounter is the key here. Regardless of whether a patient’s condition had stabilized and at what point the services were performed, if these services were performed during the critical care episode/visit/encounter, they are part of that encounter and payment is included with CPT 99291. The services may be reported as a separate line item, but not with modifier -59.

For example, a patient arrives at the hospital in the morning and has a chest x-ray and laboratory work with venipuncture. The patient leaves the hospital. Later that same day, the patient is involved in a motor vehicle accident and receives critical care services in the ED. Because one outpatient claim is submitted per date of service, the encounters are combined on one claim. The chest x-ray and venipuncture from the morning visit may be submitted with modifier -59 because they occurred during a separate and distinct encounter/visit.

Unless you have documentation to support that you provided these services during a separate visit/encounter, your MAC’s decision is correct.

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, president of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

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