Part B Insider (Multispecialty) Coding Alert

Hint: Just because your doctor visits the ICU doesn't mean he can report critical care. Most medical practices report outpatient E/M codes ( CPT 99201 - 99215 ) every day, but some Part B providers are still falling victim to several of the most common E/M myths. Button up your coding processes by dispelling these three commonly-held misunderstandings. When reporting 99211 "incident to" a physician, you should bill it under the name of the physician on record for that patient. Myth 1:When a service such as a nurse visit (99211, Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of the physician) is billed incident to the physician, make sure you file the claim under the supervising physician's name. The OIG recently found that many practices are billing incident to services under a physician's name who was not on the premises during the encounter. Reality: Often, practice management systems use the physician of record rather than the supervising physician when billing services. This arrangement makes allotting finances between physicians easier, but it causes incident to criteria to appear to be unmet. "Incident to" requires that the supervising physician is directly available, generally considered to be in or immediately adjacent to the office suite. Myth 2: If the physician sees a patient in the intensive care unit (ICU), he should always report his services using critical care codes (99291-99292). Reality: You can't automatically bill critical care simply because the place of service is the intensive care unit (ICU). If your physician evaluates a new patient in the ICU but does not perform critical care services, you'll report an initial hospital care code such as 99221 (Initial hospital care, per day, for the evaluation and management of a patient ...). Critical distinction: Critical care is not location-based; rather, it describes a specific kind of care. You must meet the following criteria to bill for critical care:

• The patient must have a critical illness (usually defined as a critical organ system failure or a shock-like syndrome)
• The physician must document at least 30 minutes of time spent directly with the patient or on the floor (hospital unit) limited only for that patient
• The physician must document highly complex decision making to assess, manipulate, and support vital system function(s) to treat the critical illness or prevent further deterioration of the patient's condition.

Typically, the physician providing critical care monitors the patient for an extended time and obtains opinions and advice from multiple specialties to create an overall care plan.