Physician not reporting critical care time

lesleeks

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I have a problem with a physician in our ED not reporting his critical care time so the facility can report it for the revenue. I am trying to find documentation on CMS or any other supporting site to take with me to Quality Assurance to let them know manipulating documentation for maximum revenue is not okay. Does anyone have any pointers on where to send me? Thanks.
 

thomas7331

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I have a problem with a physician in our ED not reporting his critical care time so the facility can report it for the revenue.
This doesn't make much sense to me - why they would do this or why this would be manipulating documentation - could you provide a little more detail about what the physician and facility are doing? When you say not reporting do you mean not billing or not documenting? And if so, why? Professional and facility fees are separate things that usually don't overlap, so I don't understand how there could be any benefit to a facility's revenue by having the physician not report some of their services. Perhaps the physician has misunderstood something, or been given incorrect information by someone at the facility.
 

lesleeks

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ACEP coding guidelines state-

Under OPPS, the time that can be reported as Critical Care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or critically injured patient. If the physician and hospital staff or multiple hospital staff members are simultaneously engaged in this active face-to-face care, the time involved can only be counted once.

The physician is aware of this, as well as the nursing staff. Purposely not documenting critical care time or anything that happens during an encounter would need to go to Quality Assurance.

I hope that helps clear up the issue I am having a little :)
I am just looking for a little help with some resources to help them understand another point of view.
 
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thomas7331

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I'm still not quite clear on this. OPPS governs how a facility reports and is paid for service, and that would be correct, the facility would report the total time spent providing critical care to that patient, regardless of the number of staff involved - since this is a facility/technical fee, the facility can only count the total time used in their facility. However, physicians are not paid under OPPS, they are paid under the PFS. The physician would still bill for their critical care services as a professional service. This would not be counting the time more than once since this is not a hospital or OPPS charge. The physician can and should bill for their services, and this would not have any bearing on how the hospital reports it, other than the fact that both entities would use the same medical record to support their charges, and not documenting would only hurt both of them.

You're correct that failure to document would be a quality issue. But I can't understand what the reasoning for doing this would be. The physician would be undercutting their own revenue by doing this and it would not benefit the facility's revenue at all. Or am I still missing something?
 
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