Comparative Billing Reports

CBR201804 Critical Care Services FAQs

General
Clinical and Billing
Report Specifics
 
General
Did I receive a CBR because I am billing my claims incorrectly?

Receiving this CBR means that your billing patterns for critical care evaluation and management (E/M) services are different from your peers. It does not necessarily indicate that your billing is incorrect. Your patterns can vary for many reasons, such as the region where you practice, your specialty, or patient acuity. If you still have questions and/or concerns after reviewing your CBR, please contact the CBR Support Help Desk by telephone at 1-800-771-4430 or by email at CBRSupport@eglobaltech.com.

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Why were critical care E/M services selected as a CBR topic?

Critical care E/M was chosen because improper payment rates are high for providers of these services. Based on a 2017 report, many critical care E/M services billed were not medically necessary and the documentation submitted did not meet Medicare criteria. For more details on this report, select the following web link: 2017 Medicare Fee-Service Supplemental Improper Payment Data.

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Will I be audited since I received a CBR?

The purpose of CBRs is to inform providers about their billing and payment patterns. The CBR team does not conduct audits or have access to medical documentation needed to perform audits of claims. It may be beneficial, however, for you to conduct self-audits from time to time. Resources that can help with setting up an audit process are located on our CBR website page at the link titled, Self-Audit Help.

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Where can providers find additional information about CBR201804?

Providers may benefit from the explanations of the Tables in the CBR, which are found at the web link titled, CBR201804 Statistical Debriefing. Additionally, the links for the references and resources used in this CBR are located at CBR201804 Recommended Links.

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Clinical and Billing
How does Medicare define critical care?

According to the Medicare Claims Processing Manual, “Critical care is defined as the direct delivery by a physician(s) medical care for a critically ill or critically injured patient. A critical illness or injury acutely 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…Critical care services must be medically necessary and reasonable.” More information about critical care is found at the following web link: Medicare Claims Processing Manual, Chapter 12, Section 30.6.12

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What is considered vital organ system failure?

Vital organ system failure can include, but is not limited to, central nervous system, circulatory system failure, shock, hepatic, renal, metabolic, and respiratory failure.

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What CPT® codes should I use to report critical care E/M services, and how should I report them?

Critical care is reported using CPT® codes 99291 and 99292, and is based on the time a physician spends with the patient. CPT® codes 99291 and 99292 and durations of time are listed in the table below. We have also listed CPT® codes 99232 and 99233 that are appropriate to use when the duration of critical care is less than 30 minutes. 

 

CPT® Code

Total Duration of Critical Care

99232 or 99233 or other appropriate E/M code

Less than 30 minutes

99291 x 1

30 – 74 minutes

99291 x1 and 99292 x 1

75 – 104 minutes

99291 x 1 and 99292 x 2

105 – 134 minutes

99291 x 1 and 99292 x 3

135 – 164 minutes

99291 x 1 and 99292 x 4

165 – 194 minutes

99291 - 99292 as appropriate

194 minutes or longer

     Medicare Claims Processing Manual, Chapter 12, Section 30.6.12

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Must critical care services be provided in the emergency department?

Medicare beneficiaries can receive critical care services in any location as long as the services are medically necessary and meet the critical care definition. Critical care treatment is not limited to critical care areas, such as the emergency department, coronary care unit, or intensive care unit.

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Will Medicare pay for critical care services and emergency department services provided on the same date?

It depends on the circumstances. The Medicare Claims Processing Manual (Chapter 12, Section 30.6.12) gives the following example of correct billing of time:

 

  • A patient arrives in the emergency department (ED) in cardiac arrest. The emergency department physician provides 40 minutes of critical care services. A cardiologist is called to the ED and assumes responsibility for the patient, providing 35 minutes of critical care services. The patient stabilizes and is transferred to the coronary care unit (CCU). In this instance, the ED physician provided 40 minutes of critical care services and reports only the critical care code (CPT® code 99291) and not also emergency department services. The cardiologist may report the 35 minutes of critical care services (also CPT® code 99291) provided in the ED. Additional critical care services by the cardiologist in the CCU may be reported on the same calendar date using 99292 or another appropriate E/M code depending on the clock time involved.”

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Can a physician provide critical care services to more than one patient at a time?

Per Chapter 12 of the Medicare Claims Processing Manual, critical care is the time “spent at the immediate bedside or elsewhere on the floor or unit so long as the physician is immediately available to the patient…For any given period of time spent providing critical care services, the physician must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.” For additional information, select this web link: Medicare Claims Processing Manual, Chapter 12, Section 30.6.12.

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Where can I find examples of patients whose conditions may warrant critical care services?

Some examples where critical care may be approved are found in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.12:

 

  • “70 year old admitted for right lower lobe pneumococcal pneumonia with a history of chronic obstructive pulmonary disease (COPD) becomes hypoxic and hypotensive 2 days after admission.
  • An 81 year old male patient is admitted to the intensive care unit following abdominal aortic aneurysm resection. Two days after surgery, he requires fluids and pressors to maintain adequate perfusion and arterial pressures. He remains ventilator dependent.”

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Where can I find examples of patients whose conditions may not warrant critical care?

Examples of services that may be denied as critical care are found in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.12:

 

  • “Daily management of a patient on chronic ventilator therapy does not meet the criteria for critical care unless the critical care is separately identifiable from the chronic long term management of the ventilator dependence.
  • Management of dialysis or care related to dialysis for a patient receiving end-stage renal disease (ESRD) hemodialysis does not meet the criteria for critical care unless the critical care is separately identifiable from the chronic long term management of the dialysis dependence (refer to Chapter 8, Section 160.4).”

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Report Specifics
How was the data obtained for this report?

This report is an analysis of providers listed as the Rendering NPI on Medicare Part B claims for critical care E/M services (CPT® codes 99291, 99292), and includes claims with dates of service from January 1, 2017 to December 31, 2017. This analysis was based on the latest version of claims available from the Integrated Data Repository (IDR), as of April 12, 2018 and excludes claims with the rendering specialty of Emergency Medicine (93). For more information about the IDR, see the following link: CMS Integrated Data Repository (IDR).

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How were providers selected to receive CBRs?

There are more than 86,000 providers nationwide with allowed charges for the CPT® codes included in this report. The criteria for receiving this CBR are:

  • Provider is significantly higher than at least one of the peer groups on at least one of the measurements studied
  • Provider is near or above the 75th percentile in allowed charges ($10,000)
  • Provider had at least 25 beneficiaries

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What do the comparison outcomes mean?

The four possible outcomes for the comparisons between the provider and peer groups are:

  • Significantly Higher - Provider’s value is higher than the peer value and the statistical test used confirms significance
  • Higher – Provider’s value is higher than the peer value, but either the statistical test does not confirm significance or there is insufficient data for comparison
  • Does Not Exceed - Provider’s value is not higher than the peer value
  • N/A (Not Applicable) - Provider does not have sufficient data for comparison

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What is shown in Table 1?

Table 1 is titled Summary of Your Utilization for Critical Care E/M Services. This table lists the CPT® codes, types, allowed charges, allowed services, visits, and beneficiary counts used in this report.  Please note that the totals may not be equal to the sum of the rows due to rounding. Also, the beneficiary and visit counts are unduplicated counts for each row and the total. For example, a beneficiary receiving multiple services with different CPT® codes within this time period would be counted in the beneficiary count in each applicable row; however, this beneficiary would be counted only once in the total row. To review the sample provider’s report, select this web link: CBR201804 Sample CBR.

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What does Table 2 show? 

Table 2 is an analysis of the Percentage of Services Submitted with Modifier 25. The provider’s value is calculated by taking the Number of Services with Modifier 25 appended and dividing by the Total Number of Services. The provider’s value is then compared to the overall percentage for his/her state and the nation using the chi-square statistical test. To view the results for all states, select the following link: CBR201804 Statistical Debriefing.

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What does Table 3 show?

Table 3 is an analysis of the Average Number of Visits per Beneficiary. The provider’s value is calculated by taking the Number of Dates of Service for Critical Care (Visits) and dividing by the Total Number of Beneficiaries. The provider’s value is then compared to the overall average for his/her state and the nation using the t-test. To view the results for all states, select the following link: CBR201804 Statistical Debriefing.

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What is shown in Table 4?

Table 4 is an analysis of the Average Allowed Charges per Beneficiary. The provider’s value is calculated by taking the Total Allowed Charges for Critical Care and dividing by the Total Number of Beneficiaries. The provider’s value is then compared to the overall average for his/her state and the nation using the t-test. To view the results for all states, select the following link: CBR201804 Statistical Debriefing.

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