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Medical Coding News Archives

Correct Critical Care Billing Still Up in the Air

February 26, 2008:
What seemed to be established policy regarding separate billing for critical care services is now up in the air if a new communication from the Centers for Medicare and Medicaid Services (CMS) is correct.

Since the beginning of the outpatient prospective payment system’s (OPPS) inception in 2000, facilities have understood that critical care codes and related services such as chest x-rays and EKGs could be billed separately, a radical departure from physician billing guidelines for critical care services. However, CMS published an FAQ on December 19, 2007, that has facilities in an uproar, and no clear guidance has yet to be issued from the agency.

The CPT® manual states that certain services are included in the critical care codes and should not be reported separately. Such services include the interpretation of cardiac output measurements (93561, 93562), chest x-rays (71010, 71015, 71020), pulse oximetry (94760, 94761, 94762), blood gases and information data stored in computers (e.g., ECGs, blood pressures, hematologic data [99090]); gastric intubation (43752, 91105); temporary transcutaneous pacing (92953); ventilatory management (94002–94004, 94660, 94662); and vascular access procedures (36000, 36415, 36591, 36600).

However, an April 7, 2000, Federal Register notice states: “If other services, such as surgery, x-rays, or cardiopulmonary resuscitation were furnished on the same day as the critical care services, we would allow the hospital to bill for them separately.”

But the above-mentioned FAQ published on December 19 states:

Q: What services are included in CPT® code 99291 (Critical care, first 30–74 minutes) and should therefore not be billed separately?

A: Hospitals must follow the CPT® instructions related to CPT® code 99291. Any services that CPT® indicates are included in the reporting of CPT® code 99291 should not be billed separately by the hospital.

This FAQ appears to directly conflict with prior guidance from CMS and confuses the issue of what a facility can or cannot bill for separately when critical care is rendered. From the 2000 Federal Register notice and an FAQ published in that same year, hospitals have concluded that services listed as included in critical care for the physician were billable in a hospital setting. This conclusion was confirmed in a more recent FAQ in which CMS indicated it removed the Correct Coding Initiative (CCI) edits from the Outpatient Code Editor (OCE), edits that would have stopped providers from billing these services separately. However, the new FAQ clearly states that hospitals should not bill these listed services separately.

CMS has stated during a recent Open Door Forum call that the 2000 guidance is no longer correct, as CMS took it off its website in 2003. The agency did not comment about the Federal Register notice from 2000, however, still leaving doubt as to what the correct policy is.

Deborah C. Hall
Clinical/Technical Editor

CPT is a registered trademark of the American Medical Association.


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