A Chance to be Proactive Instead of Reactive
Proper Documentation of Inpatient Order and Critical Care Services
Hospitals are seeing some relief from Medicare medical reviews due to the RAC moratorium and the Probe and Educate program. But this does not mean that you should not pay attention to proper documentation requirements for both inpatient and outpatient services. In fact, this decreased activity allows hospitals some extra time to focus on proactive improvements. This month I will address one outpatient issue and one inpatient issue that are often the focus of medical reviews.
Since the Medicare Administrative Contractors (MACs) are continuing with the Probe and Educate reviews, medical review activity on their websites is minimal to mostly none. I was surprised to find the results of widespread targeted reviews for several DRGs posted on Cahaba’s website on May 23, 2014. We thought all such reviews had been discontinued during the Probe and Educate period. We have reached out to Cahaba to determine if these review results are from the Probe and Educate review, from a prior timeframe, or if there is another explanation.
Specificity of Inpatient Admission Order
In addition to the standard medical necessity findings, the Cahaba DRG reviews identified that some of the records submitted did not have physician orders that clearly indicated an inpatient admission versus outpatient admission. The 2014 IPPS update codified that an inpatient admission order documented in the patient’s medical record is required as a condition of payment for a Medicare inpatient admission. The specific requirements for inpatient orders can be found in the January 30thCMS document on inpatient admission order and certification. Generally, the order must specify admission for inpatient services. The wording of the order should be such that an outside reviewer could clearly determine the intention to admit the patient as an inpatient. Only in extremely rare circumstances, when the intent for inpatient admission can be clearly derived from the medical record, will a CMS reviewer accept a claim as an inpatient admission when the order is missing, illegible, or ambiguous.
Critical Care Services
A frequent focus of Medicare reviews for outpatient services is critical care services. A February 2014 Cahaba article explains the requirements for appropriate billing of critical care CPT codes 99291 and 99292.
- Critical care is the direct delivery of care by a physician or hospital staff to a patient with a critical illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.
- Critical care is based on time. Documentation must include the amount of time the physician or hospital staff spent providing critical care to the patient.
- CPT code 99291 is for 30-74 minutes of critical care. Critical care lasting less than 30 minutes is not separately billable. Each additional 30 minutes beyond 74 minutes is reported with CPT code 99292.
- Documentation must support that the physician and/or hospital staff were engaged in active face to face critical care of a critically ill or critically injured patient.
- Per the Correct Coding Initiative (CCI) manual, the time devoted to performing cardiopulmonary resuscitation (CPT code 92950) should not be included in critical care E&M service time.
Cahaba is also reviewing Part B (physician) billing of critical care services. See the findings and comments for this review at Part B Critical Care Review.
So use your time wisely and determine if these or other documentation issues at your facility need to be improved.
MAC Medical Review Announcements/Findings for this month.
Article by Debbie Rubio
This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.