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Prolonged services and Critical care

  1. #1
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    Question Prolonged services and Critical care
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    Can you bill Prolonged services and Critical care together? I have a bill that was for 99223 ( Subsequent Hospital visit High complexity) and the doctor documented he spent 2 and 1/3 hours with patient face to face but then after that the patient went into shock and after that he spent 1 hour in critical care with the patient. Medicare is denying the 99233 code and the prolonged services code 99356 ( Prolonged services 1st hour) and paying the critical care code 99291. Is there a way to get all three paid?

  2. #2
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    Tacoma, WA
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    Quote Originally Posted by moremopars1 View Post
    Can you bill Prolonged services and Critical care together? I have a bill that was for 99223 ( Subsequent Hospital visit High complexity) and the doctor documented he spent 2 and 1/3 hours with patient face to face but then after that the patient went into shock and after that he spent 1 hour in critical care with the patient. Medicare is denying the 99233 code and the prolonged services code 99356 ( Prolonged services 1st hour) and paying the critical care code 99291. Is there a way to get all three paid?
    Pub-100 References - 100-4,12,30.6.9

    Payment for Inpatient Hospital Visits - General (Codes 99221 - 99239)
    A. Hospital Visit and Critical Care on Same Day When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical Care Services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service. Hospital emergency department services are not paid for the same date as critical care services when provided by the same physician to the same patient.
    During critical care management of a patient those services that do not meet the level of critical care shall be reported using an inpatient hospital care service with CPT Subsequent Hospital Care using a code from CPT code range 99231 - 99233.
    Both Initial Hospital Care (CPT codes 99221 - 99223) and Subsequent Hospital Care codes are "per diem" services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.
    Physicians and qualified nonphysician practitioners (NPPs) are advised to retain documentation for discretionary contractor review should claims be questioned for both hospital care and critical care claims. The retained documentation shall support claims for critical care when the same physician or physicians of the same specialty in a group practice report critical care services for the same patient on the same calendar date as other E/M services.

    I would appeal, this is Medicare's own guideline on this coding situation.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

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