Wiki Critical Care denied as Global

[Sefstratis]

Has anyone seen new denials from Medicare for 99291's billed in addition to a procedure on the same day? We are pulmonary/critical care group, and have always been paid for 291's in conjunction with a separate procedure, using our modifier 25 correctly, and procedures are not considered "bundled". I'm wondering if this is an edit issue at Palmetto. It began in December 2010.

 

[eadun2000]

Need to know what was billed in order to give an accurate answer. If you could please say what was billed along with the dx codes it would be a big help.

 

[brodel]

I code for a group of pulmonology/critical care Dr's as well. We have not run into that problem but I don't do the billing side of it. I have a couple question for you though since you code the same specialty as I do.

Do you count "weaning" from a ventilator as high in the table of risk?

Do your Dr.'s see a lot of patients with cystic fibrosis? We see a lot of them who come into the hospital and are given IV vancomycin (for example) or they are on tacrolimus (both are considered "high" risk drugs that require monitoring). However, often by the third day patients are "improving" while they are still on the antibiotics... my docs want to keep billing the visits as "high" but I am inclined to lower them because the patients are responding positively and improving. It seems I can get a level 3 sub. care day on paper yet the patient's are not "unstable". Do you encounter this too?

Any input would be greatly appreciated!

 

[andrewbetterton]

My office has had the exact same problem. We're also Pulmonary/Critical Care, and it started late 2010. Our MAC is Palmetto. The denials are semi-random, but always involve bundling 99291 or 99292, though it isn't clear what Palmetto thinks the critical care is supposed to be bundled with. We use the 25 modifier.
For example, we'll bill critical care, dx=respiratory failure, with a bronchoscopy, and they'll pay the bronch but not the critical care.