SCCM Resource Library-Pay Attention When Coding Critical Care

Pdf Summary

The document stresses the importance of accurate documentation and coding in medical billing, particularly concerning critical care services, due to increasing scrutiny by government agencies and payers like Medicare. Between October 2016 and March 2018, Medicare paid $1.6 billion for critical care services. An audit at the University of Pennsylvania identified non-compliance in 14 out of 150 reviewed claims. Critical care services are defined by Medicare as treatments provided directly by a qualified practitioner to a critically ill or injured patient with vital system impairments making them susceptible to life-threatening conditions.<br /><br />The CMS (Centers for Medicare and Medicaid Services) frequently audits claims via the Comprehensive Error Rate Testing (CERT) program to ensure compliance and to protect the Medicare Trust Fund. Data mining is employed to analyze large databases to find anomalies. In 2020, the CERT program's findings highlighted significant upcoding errors, particularly within critical care services, where 13.2% of claims were upcoded. This involved billing at a higher service level than was medically necessary or documented.<br /><br />Physicians should pay attention to documentation errors, such as insufficient support for medical necessity or CPT coding errors. CERT reported high rates of documentation-related errors in Medicare Part B claims. For critical care claims, the improper payment rate was 19.7% with 72.2% of claims improperly coded, often when these services should have been reported as regular hospital visits.<br /><br />Practices are advised to conduct audits, including for critical care services, to prevent improper billing. By running frequency reports and reviewing E/M services and procedures frequently billed, practitioners can ensure compliance and reduce the risk of overpayments. Given current trends, medical practitioners should aim for accuracy to avoid future audits and financial repercussions.

Asset Subtitle

Administration, Quality and Patient Safety, 2021, 00:04:52

Asset Caption

This article was first published in the Summer 2021 issue of Critical Connections.

It is important to review your documentation periodically to ensure compliance with correct coding procedures, documentation, and medical necessity support for the service provided. Critical care services are currently on the Office of Inspector General Work Plan and under government and payer scrutiny. Between October 1, 2016, and March 31, 2018, Medicare paid $1.6 billion for critical care services. An audit of critical care services was performed on clinical practices at the University of Pennsylvania because it was one of the 10 highest-paid providers. Of the 150 claims reviewed, 14 did not comply with Medicare requirements for reporting critical care services.

Critical Connections, the critical care industry's only newsmagazine, provides information on cutting-edge topics in critical care useful to the entire multiprofessional team.Deborah Grider, CDIP, CCS-P, CPC, CPC-I, CPC-P, COS, CEMC, CPMA

Meta Tag

Content Type Article

Knowledge Area Administration

Knowledge Area Quality and Patient Safety

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Learning Pathway Billing and Documentation

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Economics

Tag Informatics

Year 2021

Keywords

Billing and Documentation

medical billing

critical care services

Medicare

documentation accuracy

CMS audits

CERT program

upcoding errors

compliance

CPT coding

improper payments

	Society of Critical Care Medicine 500 Midway Drive Mount Prospect, IL 60056 USA Phone: +1 847 827-6888 Fax: +1 847 439-7226 Email: support@sccm.org	Contact Us About SCCM Newsroom Advertising & Sponsorship DONATE	MySCCM LearnICU Patients & Families Surviving Sepsis Campaign Critical Care Societies Collaborative	GET OUR NEWSLETTER
© Society of Critical Care Medicine. All rights reserved. \| Privacy Statement \| Terms & Conditions The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.