MRA Thought of the Day – Avoid Revenue Loss with Critical Care Services


Julie-Leah J. Harding CPC, RMC, PCA, CCP, SCP-ED, CDIS Director of Education Julie-Leah J. Harding CPC, RMC, PCA, CCP, SCP-ED, CDIS Director of Education

A physician’s office notices a significant loss in revenue in relation to critical care services. What is causing this and what can be done on the HIS side to remedy the issue?

Here are my thoughts…

Time Capture:

Problematic for many providers is remembering what to include in their documentation while trying to adhere to a busy and complex workflow/environment. CPT® 99291 poses the challenge of time capture consistently. Time according to CPT®, defined as “time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit.” We are constantly reminding providers that with patients who are 72 months of age or older we can report CPT® 99291 for the first hour of care 30 to 74 minutes; then for additional time we then can report CPT® 99292 for each additional 30 minutes. The documentation required aside of updating managed disease processes and co-morbidities daily – the provider rending the service must document the total critical care time spent with the patient … in the attestation that must be amended to each documentation entry.

Updating the Patient’s Managed Diagnoses:

Documentation and updating managed diagnoses often get into a common rut with the new age of EHR’s is cut and paste. In doing so the providers are forgetting to modify or update what they managing and more importantly not conveying Critical-Nature of the patient’s illness, according to CPT® which “impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition;” Many payers have retracted critical billing because of the lack of the of clarity in the patient’s status. Realize Critical Care CPT®s are reimbursed approximately 25% higher than a comprehensive evaluation and management CPT® code; if down-coded by a payer, the CPT®s are often changes to subsequent in-patient hospital care CPT® codes 99231-99233.

Stop the Cut and Paste of Documentation:

We have also seen with cut and paste notes are under enormous scrutiny and within the critical care areas there are same concerns. It is easy to copy the day prior’s documentation but payers and the OIG are taking note, and it can be costly: E/M improper documentation due to cloned notes, identical documentation- OIG will assess the extent to which CMS made potentially inappropriate payments for E/M services and the consistency of E/M medical review determinations. OIG will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the code for the service based upon the content of the service and have documentation to support the level of service reported. (CMS’s Medicare Claims Processing Manual, Pub. No. 100-04, ch. 12, § 30.6.1.) (OEI; 04-10-00181; 04-10-00182; expected issue date: FY 2013; work in progress.

What are your thoughts?

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