Health Information Management

Q/A: Payment for critical care and separately reported services

APCs Insider, August 3, 2012

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Q: Since the AMA changed the instructions regarding hospital reporting of critical care services for 2011, when is CMS going to start paying hospitals for the services that are reported along with critical care?

A: The AMA did revise the instructions for how codes for ancillary services should be reported by hospitals when reporting a critical care level of service. In the January 2011 CPT® code update, under the paragraph that describes the services considered to be included in CPT 99291 (critical care, evaluation and management of the critically ill or critically injured patients; first 30 – 74 minutes0, the AMA added an instruction that states, “Facilities may report the above services separately.”
CMS then instructed hospitals to follow the CPT guidelines and report these services and associated charges separately when the services were provided with critical care. However, CMS also noted in Transmittal 2141 that it would institute claims processing edits that would continue to package the payment for these services into the payment for the critical care visit (CPT 99291).
CMS is using claims data for CY 2011 to set the payment rates for CY 2013. In the CY 2013 OPPS proposed rule, CMS notes that these claims are the first claims that would reflect the separate reporting of services under the updated CPT guidelines. When CMS reviewed the claims data, it found that the CY 2011 data showed no change in the cost/charges related to CPT codes 99291 and 99292. The claims also failed to show a significant increase in the ancillary services reported on these claims.
“The lack of a substantial change in the services reported on crucial care claims, along with the increases in the line item costs and charges for critical care services, strongly suggests that many hospitals did not change their billing practices” following the change to the CPT guidelines, CMS stated in the 2013 OPPS proposed rule.
Because the claims data does not support a change in billing practices, CMS believes it is “inappropriate to pay separately in CY 2013 for the ancillary services that hospitals may now report in addition to critical care services.” CMS is proposing to continue its policy of packaging payment for the ancillary services reporting on the same date of service into CPT code 99291, noting that providing separate payment would create an overpayment situation based on the hospital claims data.
Each facility should review its current reporting practices for critical care (CPT 99291) and the ancillary services that were considered to be included prior to January 2011. Coders and billers should report these services on a separate line item with a CPT code and charge to reflect the cost and the specific services provided to the individual patient.
Facilities should review exactly what is being reported on the claim and coming back on the remittance advice. Some claim scrubbers require the removal of a service if a modifier is not applied and the cost/charge is lost when the claim is finally submitted. If a facility is reporting the line item separately but without a modifier to indicate the service is separate and distinct from critical care, the line item should be allowed to pass through the scrubber edits.
Some scrubbers and claims administrator software require the line item or CPT code be removed. In this instance, that is not an appropriate rule – the line item must be reported so that CMS gets the cost/charge information per its guidance and the CPT guidelines. The modifier or lack of modifier will drive payment during CMS claims processing. If this situation is occurring, someone in your facility should discuss a software correction with the vendor(s) as soon as possible. It is imperative that these services be reported individually and correctly to insure that CMS has the claims data to set appropriate payment for services provided to beneficiaries.


Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Fla., answered this question.

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