June 30, 2008
Medical Review Frequently Asked Questions
The following represent a variety of questions the Medical Review department has received. CIGNA Government Services will address at least quarterly “Frequently Asked Questions” related to coverage and local medical review policy issues. Providers may submit questions to the website at http://www.cignagovernmentservices.com/medicare_dynamic/customer_service/index.html
Critical Care Visits by Two Physicians on the Same Date of Service
Question: When an on-call physician also performs a critical care encounter the same date of service as another physician, how should this be billed?
Answer: Critical Care Services were recently addressed by CMS Transmittal # R1530CP. Related to above question, the supporting MLN Matters article states:
“Physicians in the same group practice, with different specialties, who provide critical care to a critically ill or critically injured patient may not always each report the initial critical care code (CPT 99291) on the same date. When these physicians are providing care that is unique to his/her individual medical specialty, and are managing at least one of the patient’s critical illness(es) or critical injury(ies); then the initial critical care service may be payable to each. However, if a physician (or qualified NPP) within a group provides “staff coverage” or “follow- up” for another group physician who provided critical care services on that same calendar date but has left the case; the second group physician (or qualified NPP) should report the CPT critical care add-on code 99292, or another appropriate E/M code.”
Since CPT code 99292 is an add-on code, if it is reported under the second physician’s number, it will be denied (since the second physician neither performed or billed the add-on code’s corresponding primary code, 99291). Therefore, in this scenario, the 99292 visit should be billed using the number of the physician who billed the 99291 visit.
See Medicare Learning Network Matters article #5593 via the following link for further examples and guidelines: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5993.pdf
Nursing Facility Admission By The Surgeon During the Postoperative Period
Question: Can the surgeon be paid for this?
Answer: If the nursing facility stay is related to the operation, then the surgeon cannot be paid. If the nursing facility stay is unrelated to the surgery, then the surgeon could be paid.
CMS Publication 100-4, The Medicare Claims Processing Manual, chapter 12, section 30.6.9.2, subsection D states:
“Contractors do not pay for a nursing facility admission by a surgeon in the postoperative period of a procedure with a global surgical period if the patient’s admission to the nursing facility is to receive post operative care related to the surgery (e.g., admission to a nursing facility to receive physical therapy following a hip replacement ). Payment for the nursing facility admission and subsequent nursing facility services are included in the global fee and cannot be paid separately.”
Additionally, this reference says:
“If a surgeon is admitting the patient to the nursing facility due to a condition that is not as a result of the surgery during the postoperative period of a service with the global surgical period, he/she bills for the nursing facility admission and care with a modifier “-24” and provides documentation that the service is unrelated to the surgery (e.g., return of an elderly patient to the nursing facility in which he/she has resided for five years following discharge from the hospital for cholecystectomy).”
This manual can be accessed via the following link: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf
