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CAPC Palliative Care Discussion Forum
Billing and Finance
Billing for family meetings + prolonged services Author: dianeemeier [CAPC Faculty]
Date: Mar 19, 2009 11:38 am
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I am starting to use the critical care code, 99291, more frequently for a prolonged ICU interaction, since the patient does not need to be present. guidelines indicate EOL discussions are approp for 99291 code in critical care situation.
99291 reimburses at a $ amount equiv to a 99255 and documentation and time requirements are much lower.
An intensivist here tells me that they get paid 100% for 99291 but they are also audited nearly 100%: they xerox their notes at the time of visit to have them immediately available.
We have been getting paid for 99291 and not yet audited. (We have been audited for 99255--happy to discuss with anyone in Austin.)
Diane E. Meier, MD, FACP
Director, Center to Advance Palliative Care
Director, Hertzberg Palliative Care Institute
Professor, Geriatrics and Internal Medicine
Mount Sinai School of Medicine
New York, NY
Julie Pipke CPC, Reimbursement Mngr. MCW
Diane E. Meier, MD, FACP
Director, Center to Advance Palliative Care
Director, Hertzberg Palliative Care Institute
Professor, Geriatrics and Internal Medicine
Mount Sinai School of Medicine
New York, NY
Diane E. Meier, MD, FACP
Director, Center to Advance Palliative Care
Director, Hertzberg Palliative Care Institute
Professor, Geriatrics and Internal Medicine
Mount Sinai School of Medicine
New York, NY
To address the issue - can prolonged care codes be billed for family visits in view of the change in the CPT code language effective Jan 2009: I asked UPP Compliance about this in a February email. This resulted in the below document being created by UPP Compliance. In summary - NO; at this time we are not billing prolonged care for family discussions. This is direction from UPP Compliance as noted in the below email:
"Be aware that there exists a distinct difference in the measurement criterion for inpatient prolonged services between the rules currently defined in the CMS Claims Processing Manual and the AMA CPT Manual 2009. CMS requires that the time-based measurement criterion for inpatient services is still “face-to-face” time with the patient whereas AMA’s CPT 2009 has changed this measurement criterion to “unit/floor” time. Both CMS and AMA agree that “face-to-face” time with the patient is the measurement criterion for office/outpatient services. All PSD must continue to enumerate inpatient prolonged services based on the direct “face-to-face” time. See the attached guidance document for complete details."
Dawn A. Moody, RN, CPC
Senior Medical Auditor
Division of General Internal Medicine
UPMC Health System
412-683-7649
moodyda@upmc.edu
Documentation and Coding for Prolonged Services
UPMC Physician Services Division Compliance Guidance Document
Documentation and Coding for Prolonged Services
NOTE: this announcement generally applies to UPMC Physician Services Division (PSD) billing providers (physicians and non-physician practitioners) that render and bill prolonged services add-on codes (CPT codes 99354 - 99357). However, this announcement also makes a general recommendation to document start and end times for all time-based services. If you do not render prolonged services or other time-based services, then you may ignore this announcement.
In July 2008, the Center for Medicare and Medicaid Services (CMS) made changes and clarifications to their rules regarding documentation and billing for prolonged services add-on codes. It is noted that these rules are fairly complex with regard to when these prolonged services (add-on) codes are legitimately billable and how the codes are selected. The complexity may be best evidenced by the fact that CMS publishes time threshold tables to aid providers with correct code selection. Because of the complexity of this coding, and for the two additional reasons discussed in the following paragraphs, it has been decided to publish a compliance guidance document on this subject.
Be aware that there exists a distinct difference in the measurement criterion for inpatient prolonged services between the rules currently defined in the CMS Claims Processing Manual and the AMA CPT Manual 2009. CMS requires that the time-based measurement criterion for inpatient services is still “face-to-face” time with the patient whereas AMA’s CPT 2009 has changed this measurement criterion to “unit/floor” time. Both CMS and AMA agree that “face-to-face” time with the patient is the measurement criterion for office/outpatient services. All PSD must continue to enumerate inpatient prolonged services based on the direct “face-to-face” time. See the attached guidance document for complete details
Another significant aspect of the CMS prolonged services rule is a requirement that the provider must document “start and end times” for the face-to-face visit with the patient in the medical record. Quoting from the rule: “…the start and end times of the visit shall be documented in the medical record along with the date of service.” The Compliance Office believes that the CMS requirement to document “start and end times” for prolonged services will likely migrate to other CMS rules for time-base services and other payers. We have already seen Highmark indicate a “start and end time” requirement (that does not exist in AMACPT Manual 2009) for a different time-based service in a specialized audit they are conducting. For these reasons, the Compliance Office urges providers to consider being proactive in documenting start and end times on all time-based services. With the prolonged services codes, documenting start and end times is an absolute requirement.
If you render and bill for prolonged services (CPT codes 99354 – 99357) the Compliance Office urges you to read the attached document and adhere to the documentation and coding instructions therein.
If that is not the case, then our careers are not financially tenable, since it may take less than 2 minutes to examine an ICU patient, but it may take hours to research the medical facts and to talk to the family.
They are citing me for not putting "face to face time" on my 99356,7 even though I listed the start and end times clearly in the margin of each note.
They are down coding and asking for money back also for my 99255 consults because even though I list the start and end times, I did not write " greater than 50% of time spent in counseling and coordination of care" .
This is infuriating and takes up my time and adds to Work Burn Out.
As with other responses here I see Medicare asking for documentation often (~30% of the time) when I do 99356,7 work. So, I too just copy the note after I write it to have in case I need to send it to them. This is a waste of time !!!
Any one have the answer on how to respond to the audit?? I hope the new Hospice & PC code "17" from CMS will help
JeffZesiger