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Critical care, two different providers, same day, same specialty

  1. #1
    Location
    Ellenville, New York
    Posts
    1,176
    Default Critical care, two different providers, same day, same specialty
    Exam Training Packages
    I have been presented with the above scenario and am in a quandy on how to handle this. At first, I just thought it would be easy enough - combine the times and submit on one claim. But...the patient was first seen by the hospitalst and he provided CC services for 45 minutes while awaiting the intensivist to answer his call. Intensivist came and provided another 45 minutes. They use the same NPI for billing, and are credentialed as the same specialty. It is proposed to have the first MD bill 99291 and the second bill separately with 99292! (Scrape me off the floor now after hearing that suggestion!) But...in order for each of them to get their RVU credit, how do we go about this?

    Thanks

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  2. #2
    Default
    Physicians in Group Practice
    • Physicians of the same specialty in the same group practice must bill and be paid as a single physician.
    • If more than one E/M (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one E/M service may be reported unless the E/M services are for unrelated problems. (Refer to instructions for use of the 76 modifier.)
    • Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.

  3. #3
    Location
    Ellenville, New York
    Posts
    1,176
    Default I may have found my answer
    Contrary to my thoughts, 99292 CAN be billed alone on a separate claim. On MLN Matters Number MM5993, there is an example given for two specialists of the same practice and specialty and the exact wording is "One physician would report CPT code 99291 for the initial visit and the second, as part of the same group practice, would report CPT code 99292 on the same calendar date if the appropriate time requirements are met." So, if I read this right, an add-on code (99292) CAN be submitted on a claim in this case without the required code (99291)????

    Here is the link to the article: http://www.cms.hhs.gov/MLNMattersArt...ads/MM5993.pdf

    No wonder we never get bored in this profession! If anyone else has other feedback, thank you.

    And thanks to tcowboys07 for your post as wel.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  4. #4
    Default
    This is fascinating! I can certainly appreciate your interpretation of the MLNMatters article. However, the Medicare Claims Processing Manual, Chapter 12 Section 30.6.12 states "Reporting CPT code 99291 is a prerequisite to reporting CPT code 99292. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician." Does the MLN article change this? Very interested in other feedback.

  5. #5
    Location
    Quincy/Hannibal
    Posts
    67
    Default Webinar
    Wednesday's Webinar by AAPC stated that you must bill them together for the same specialty. If you have access or can get access to it, it was all about CC. We bill them together and split them apart internally after receiving payment.
    Lori Cox, MBA, CPC, CPMA, CPC-I, CEMC, CHONC, AAPC FELLOW
    Coding Team Leader
    MedKoder | Medical Coding With Financial Peace
    www.medkoder.com
    lcox@medkoder.com

    2015-2018 AAPC National Advisory Board Member

  6. #6
    Location
    Ellenville, New York
    Posts
    1,176
    Default I agree with the two of you...
    and that is what I have always believed. But after reading that MLM article, I am not so sure...or am I misinterpreting what it stated???

    Thanks for your feedback...still in the research process for this topic!

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  7. Default Late Reply - New 2013 CMS Change
    I know this is quite a while after this question and answer was posted, but since it still pulls up at the top of a search regarding this issue.........

    Please see CMS transmittal 2636 regarding this exact scenario as they completed a change request to allow for the submission of 99292 on its own (unlike other add-on codes) to allow for these common scenarios. http://www.cms.gov/Regulations-and-G...ds/R2636CP.pdf

    This change replaced transmittal 2607 on 01/16/2013.

    However, on this same issue, there is a CPT Assistant FAQ from August 2016 that does not mention this CMS change and only advises for the second provider to bill an E/M. See below.

    "Evaluation and Management: Critical Care Services

    Question:How should the following scenario be reported in a facility? Physician A saw a patient early in the day and provided 50 minutes of critical care service. Physician B (colleague from the same group and medical specialty) saw the same patient later in the day and provided 35 minutes of critical care service. Total time of critical care services = 85 minutes.

    Answer:If the critical care services are provided to the same patient on the same calendar day, then it is appropriate for the facility to report E/M code 99291 for the initial time, up to 74 minutes, and one unit of code 99292 for the remaining time. If the physicians were reporting their services, physician B could not use the critical care E/M codes for his time because code 99291 may only be reported once per date and code 99292 is an add-on code that can only be reported in addition to code 99291. Physician A would report code 99291 for his time and physician B would report the appropriate E/M code for his time."
    CPT Assistant August 2016

    They certainly don't make it easy for everyone to be able to ever fully understand and properly bill for these services with all these varying allowances and/or inconsistencies.

    Thoughts?

  8. #8
    Default
    Thanks, Chappy10, for bringing this back up! Even Medicare's Claims Processing Manual seems to contradict itself. Chapter 12, Section 30.6.12 mentions several times that "Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician." However, please see paragraph I:

    However, if a physician or qualified NPP within a group provides “staff coverage” or “follow-up” for each other after the first hour of critical care services was provided on the same calendar date by the previous group clinician (physician or qualified NPP), the subsequent visits by the “covering” physician or qualified NPP in the group shall be billed using CPT critical care add-on code 99292. The appropriate individual NPI number shall be reported on the claim.

    The Manual goes on to give an example of 2 physicians - same specialty, same group - providing critical care at different times. In the example one specialist bills 99291 and his partner bills 99292.

    Strange. Is the concept of "staff coverage" or "follow-up" impactful here?

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