Critical care time fraud?

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Nocturnist

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I'm an admitting hospitalist.

My first admission tonight was a totally healthy 25 year old with intentional apap OD. Level was 110 and coming down appropriately. ER doc didn't call tox, didnt initiate NAC, just gave Zofran and a liter of fluids. I noticed said provider billed and documented 300 minutes of critical care time. This seemed a little excessive to me, until I noticed they billed 3 and 4 hours critical care time for my next 2 cases.

So I went ahead and did a little chart review. Out of their dozen or so admissions to the hospitalists during this shift (which I believe was 10 hours), said provider billed a total of *40* hours of critical care time...and that doesn't include any transfers, admissions to other services or potentially discharges I may not be privy to.

Is this normal? Legal?
Several of my hospitalist colleagues have independently noticed this trend as well over the last couple months with this physician and noted it excessive as well.
Would you do anything about this or just mind your business?
 
Seems excessive. APAP overdose does qualify for critical care time, but only time spent with the patient, documenting, discussing with consultants, researching, etc. Hard to image ever spending 5 hours actively managing an APAP overdose.

Would report it to their medical director. A CMS audit would probably expose your hospital and the physician's group to audits of multiple providers.
 
Nocturnist said:
I'm an admitting hospitalist.

My first admission tonight was a totally healthy 25 year old with intentional apap OD. Level was 110 and coming down appropriately. ER doc didn't call tox, didnt initiate NAC, just gave Zofran and a liter of fluids. I noticed said provider billed and documented 300 minutes of critical care time. This seemed a little excessive to me, until I noticed they billed 3 and 4 hours critical care time for my next 2 cases.

So I went ahead and did a little chart review. Out of their dozen or so admissions to the hospitalists during this shift (which I believe was 10 hours), said provider billed a total of *40* hours of critical care time...and that doesn't include any transfers, admissions to other services or potentially discharges I may not be privy to.

Is this normal? Legal?
Several of my hospitalist colleagues have independently noticed this trend as well over the last couple months with this physician and noted it excessive as well.
Would you do anything about this or just mind your business?
Click to expand...
Agree with @southerndoc. I'd be pissed if this were my colleague. This kind of thing just opens up the entire group to an audit. I don't need CMS trying to nitpick my charts and claw back money from me for nonsense just because some idiot billed 40 hours of CC time in a day.

I'd let the ED chief know. They will probably have a quick chat with that doctor and sort it out.
 
Also, FWIW, the most critical care time that I have ever billed on a patient in the past 10 years was probably something close to 3 hours. I doubt that I have ever billed more than 200 minutes on a patient in my life, and that includes the time I tried to transfer a RPA guy with a 2mm airway on CT, only to have no medflight or even ALS available for hours, so I rode in the back of a BLS truck with an airway kit, scalpel and syringe of ketamine in my pocket in case I needed to cric him before we arrived.
 
Rofl

I work on the money side now

Surprised no one from your CDI team jumped on that, if you have one.

Doc is 100% going to be fired
 
Nocturnist said:
I'm an admitting hospitalist.

My first admission tonight was a totally healthy 25 year old with intentional apap OD. Level was 110 and coming down appropriately. ER doc didn't call tox, didnt initiate NAC, just gave Zofran and a liter of fluids. I noticed said provider billed and documented 300 minutes of critical care time. This seemed a little excessive to me, until I noticed they billed 3 and 4 hours critical care time for my next 2 cases.

So I went ahead and did a little chart review. Out of their dozen or so admissions to the hospitalists during this shift (which I believe was 10 hours), said provider billed a total of *40* hours of critical care time...and that doesn't include any transfers, admissions to other services or potentially discharges I may not be privy to.

Is this normal? Legal?
Several of my hospitalist colleagues have independently noticed this trend as well over the last couple months with this physician and noted it excessive as well.
Would you do anything about this or just mind your business?
Click to expand...
whistle whistle

I would talk to the medical director. Medicare fraud is a big deal. You have a responsibility to address this now.
 
3-4 hours is insanity. Our highest billers reach 90-120 minutes maybe on the most sickest patients. Report this before you're caught up in the web of lies for being nearby.
 
Porfirio said:
whistle whistle

I would talk to the medical director. Medicare fraud is a big deal. You have a responsibility to address this now.
Click to expand...
Hard disagree

You go to the director when someone yells at you or does an inappropriate admission, etc

This is major fraud

Straight to VPMA is the only answer

You don't want a situation where for all we know the director already knows or told him to do it
 
Guuuuys.
He wanted to bill 30 mins of critical care time.
He just hit an extra zero on the keyboard by accident.
Probably just some boomer who can't type.

(kidding; I saw the bit in the original post where he billed like 40 hours somehow)
 
Thanks for all the replies.
To clarify, this is not a CMG. All ER docs are employed directly by the hospital.

obviously 40 hours in a shift is egregious, but in your experience is it even acceptable to bill cc hours in excess of the number of hour's in one's shift? I.e are you legally able to imply you were simultaneously managing more than one critically ill patient at a time, or should that in and of itself trigger an audit?
valianteffort said:
3-4 hours is insanity. Our highest billers reach 90-120 minutes maybe on the most sickest patients. Report this before you're caught up in the web of lies for being nearby.
Click to expand...
How tf do I as the hospitalist get caught up in the ER provider's 'web of lies' just for admitting their patient?

Agree on the rest. This doc's lowest bill was for 90 minutes and average was 180-240 minutes. Even for my sickest rapid responses on the floor I can't recall ever billing more than 200 minutes.


AlmostAnMD said:
Hard disagree

You go to the director when someone yells at you or does an inappropriate admission, etc

This is major fraud

Straight to VPMA is the only answer

You don't want a situation where for all we know the director already knows or told him to do it
Click to expand...
What is a VPMA?
I know the ER director very well. He's a good guy, i trust him to do the thing.
 
Total fraud--my understanding is that you can't bill for more time than you were actually present.

The most I've billed is 150 or so minutes and that's with the sickest of the sick. I probably bill about 30 min every other shift.
 
Nocturnist said:
What is a VPMA?
I know the ER director very well. He's a good guy, i trust him to do the thing.
Click to expand...

Every hospital has a vice president of medical affairs

Or CMO

Indeed you can go to the director but the director alone almost definitely won't know how to undo the damage already done

I guess who you tell is less relevant than just make sure you tell someone! Opens up the door to a massive audit of your entire hospital and people higher up need to know.

I'm dumbfounded how their billers and coders or your hospital systems CDI never noticed this. It's a Swiss cheese model example!
 
Nocturnist said:
Thanks for all the replies.
To clarify, this is not a CMG. All ER docs are employed directly by the hospital.

obviously 40 hours in a shift is egregious, but in your experience is it even acceptable to bill cc hours in excess of the number of hour's in one's shift? I.e are you legally able to imply you were simultaneously managing more than one critically ill patient at a time, or should that in and of itself trigger an audit?

How tf do I as the hospitalist get caught up in the ER provider's 'web of lies' just for admitting their patient?

Agree on the rest. This doc's lowest bill was for 90 minutes and average was 180-240 minutes. Even for my sickest rapid responses on the floor I can't recall ever billing more than 200 minutes.



What is a VPMA?
I know the ER director very well. He's a good guy, i trust him to do the thing.
Click to expand...
Vice-President of Medical Affairs. More commonly Chief Medical Officer.

While you are obviously not at fault, nobody comes out unscathed after a CMS audit.
 
you can’t bill multiple cases simultaneously.

You probably should bill a couple/three cases a shift (say 10-15% of patients, very generically).

I’ve approached billing 6hr of critical care in a single shift a few times, but these are 8-9hr shifts where then you stay 2 hours late and the stars align and you get 4 train wrecks a couple anaphylactics two head bleeds that you can’t transfer and that GI bleed that just empties your blood bank.

I’ve billed 0hr of critical care plenty of shifts to average that out 🙂
 
I am a liberal biller of critical care.

Sometimes I bill 40% in a shift.

Sometimes I bill 0%.

I rarely bill over 70 minutes.

The OPs example is abject fraud.
 
Yea.. there was a big Medicare case where some Nursing home doc billed over 24 hours of work in a day.. Similarly billing 40 hours in a 10 hour shift is clear fraud. I am hopeful this is an innocent mistake but seems unlikely. I do agree.. take to CMO.. stat… can do anonymously if for whatever reason you are scared.
 
TooMuchResearch said:
What's CDI
Click to expand...

Clinical documentation integrity.

An entire team dedicated to making sure **** like this doesn't happen. Physician-led, nurse supported.

OP could be in a small/unsupported system. Or have a bad team. This would be impossible to get away with more than a few days in my system
 
To answer the question, yes you can bill more than your shift's duration in critical care. However, you would need to be managing the critical patients your entire shift and then include the time you finished documenting.

Example: 10 hour shift, had 10 hours of clinical time at the bedside and then spent 2 hours documenting. You could have 12 hours of critical care time theoretically.

However, this is highly unlikely to happen at all.
 
DocEspana said:
guys....

have we considered that the doctor in question cloned himself like in multiplicity? Or maybe he is a time traveler?
Click to expand...
CMS guidelines specifically prohibit additive billing in multiverse scenarios.

“Regarding multiverse providers, only the iteration of the provider who is responsible for the majority of critical care time may submit 99291. Further iterations may not submit 99292 even if total critical care time is in excess of 75 minutes.”

Source
 
valianteffort said:
3-4 hours is insanity. Our highest billers reach 90-120 minutes maybe on the most sickest patients.
Click to expand...
My highest was 6 hours. Status epilepticus on a solo community overnight shift. Tube, line, a-line, every antiepilepic in the pharmacy, trying to keep stable waiting on a ground unit, no HEMS due to weather. 120-180 mins was nothing at my last shop before it abruptly closed. Combination of no support and ground Critical Care transport being nonexistent
 
southerndoc said:
To answer the question, yes you can bill more than your shift's duration in critical care. However, you would need to be managing the critical patients your entire shift and then include the time you finished documenting.

Example: 10 hour shift, had 10 hours of clinical time at the bedside and then spent 2 hours documenting. You could have 12 hours of critical care time theoretically.

However, this is highly unlikely to happen at all.
Click to expand...
Right. And right. Every single patient was critical. Possible but unlikely. Here it is 40 hours of cc time in a 10 hour shift. Must be some killer documentation.
 
EctopicFetus said:
Right. And right. Every single patient was critical. Possible but unlikely. Here it is 40 hours of cc time in a 10 hour shift. Must be some killer documentation.
Click to expand...

The doctor actually really cares about goals of care, and spent multiple hour-long family meetings per patient to clarify their code status even hours after his shift is done. Very commendable actually.
 
pkwraith said:
The doctor actually really cares about goals of care, and spent multiple hour-long family meetings per patient to clarify their code status even hours after his shift is done. Very commendable actually.
Click to expand...
Indeed. This is what ED docs are known for.. or.. the family after talking to said doctor decide it is better to kill themselves than talk to said doctor anymore..
 
Nocturnist said:
I'm an admitting hospitalist.

My first admission tonight was a totally healthy 25 year old with intentional apap OD. Level was 110 and coming down appropriately. ER doc didn't call tox, didnt initiate NAC, just gave Zofran and a liter of fluids. I noticed said provider billed and documented 300 minutes of critical care time. This seemed a little excessive to me, until I noticed they billed 3 and 4 hours critical care time for my next 2 cases.

So I went ahead and did a little chart review. Out of their dozen or so admissions to the hospitalists during this shift (which I believe was 10 hours), said provider billed a total of *40* hours of critical care time...and that doesn't include any transfers, admissions to other services or potentially discharges I may not be privy to.

Is this normal? Legal?
Several of my hospitalist colleagues have independently noticed this trend as well over the last couple months with this physician and noted it excessive as well.
Would you do anything about this or just mind your business?
Click to expand...

Yes that is fraud. There were cases brought forth in the legal system where a doctor billed more critical care time in a 24 hour period than possible.

Would you do anything about this? Ummmmm....at best I would tell their director in an email, say it nicely, and give him the evidence. Just point it out to the ER director. I'm not even sure I would do that...I dunno. The risk is to the ER doc, less so the ER director, some to the group, and probably not to the hospital.

There was a guy at our place who would bill 200-300 mins CC time for things that wouldn't demand it. I think he was exposed so to speak and he dialed it back. he's a good dude too.
 
BoardingDoc said:
Also, FWIW, the most critical care time that I have ever billed on a patient in the past 10 years was probably something close to 3 hours. I doubt that I have ever billed more than 200 minutes on a patient in my life, and that includes the time I tried to transfer a RPA guy with a 2mm airway on CT, only to have no medflight or even ALS available for hours, so I rode in the back of a BLS truck with an airway kit, scalpel and syringe of ketamine in my pocket in case I needed to cric him before we arrived.
Click to expand...

Yes, I routinely bill 60-120 minutes. Almost never more than that unless there are extenuating circumstances. For STEMI's that get to the cath lab in < 30 mns, I bill 35.
 
thegenius said:
Would you do anything about this? Ummmmm....at best I would tell their director in an email, say it nicely, and give him the evidence. Just point it out to the ER director. I'm not even sure I would do that...I dunno. The risk is to the ER doc, less so the ER director, some to the group, and probably not to the hospital.
Click to expand...
The doc is employed by the hospital so the hospital is 100% at risk.
 
thegenius said:
Yes, I routinely bill 60-120 minutes. Almost never more than that unless there are extenuating circumstances. For STEMI's that get to the cath lab in < 30 mns, I bill 35.
Click to expand...


You bill 35 min for a patient in ed less than 30 minutes?

Also fraud. I literally. Literally. Just got back from conference where this very issue came up. You thinking about the patient for 5 minutes absolutely does not pass muster with CMS and if you do it in large enough batches you'll either get away with it or return a looooot of money/fired
 
AlmostAnMD said:
You bill 35 min for a patient in ed less than 30 minutes?

Also fraud. I literally. Literally. Just got back from conference where this very issue came up. You thinking about the patient for 5 minutes absolutely does not pass muster with CMS and if you do it in large enough batches you'll either get away with it or return a looooot of money/fired
Click to expand...
Completely disagree. I bill critical care on every patient with a STEMI. Most are out of the department in far less than 30 minutes. My last one was 11 minutes. After the patient has left the ED, I review prior records, interpret ordered labs once they return, occasionally speak to family upon their arrival and document. A heart attack with increased probability of imminent or life-threatened deterioration is the exact essence of a situation where critical care billing is indicated. No one is broadly going after these physicians and trying to allege that you spent less than rather than more than 30 minutes on the patient just because they were in the department for less than 30 minutes. They have far bigger fish to fry and you are losing out on significant deserved income by not billing. The scenario discussed by the OP is completely different and doesn’t pass the smell test.
 
Mount Asclepius said:
Completely disagree. I bill critical care on every patient with a STEMI. Most are out of the department in far less than 30 minutes. My last one was 11 minutes. After the patient has left the ED, I review prior records, interpret ordered labs once they return, occasionally speak to family upon their arrival and document. A heart attack with increased probability of imminent or life-threatened deterioration is the exact essence of a situation where critical care billing is indicated. No one is broadly going after these physicians and trying to allege that you spent less than rather than more than 30 minutes on the patient just because they were in the department for less than 30 minutes. They have far bigger fish to fry and you are losing out on significant deserved income by not billing. The scenario discussed by the OP is completely different and doesn’t pass the smell test.
Click to expand...

I mean, both are fraud.

I know a hospital being audited over this VERY reason, a group of providers that basically put 35 minutes on every chart. There are lawyers involved.

I get you're doing it. But without quality documentation of WHY a patient in ed for 11 minutes had 35 minutes of time it's a risk. I can't emphasize that enough.

What you guys are doing is habit, habit is not law.

ED docs generally seem to understand CC billing better than more fraud that often happens upstairs but you'd NEED to explain 35 min of cc time on someone you sniffed at on the way to the cath lab

Edit for clarity:

The way you bill critical care -likely- won't be a nidus of investigation. But it, like the case i mentioned, can get caught up as a secondary investigation when being audited for something else.

Billing is complex, man. I'm only just starting to understand it after years of guessing/seeing what other people do
 
Last edited:
AlmostAnMD said:
I mean, both are fraud.

I know a hospital being audited over this VERY reason, a group of providers that basically put 35 minutes on every chart. There are lawyers involved.
Click to expand...

Critical care for a STEMI in the ED <30 minutes is not even close to 35 minutes of critical care on every chart.
 
AlmostAnMD said:
You bill 35 min for a patient in ed less than 30 minutes?

Also fraud. I literally. Literally. Just got back from conference where this very issue came up. You thinking about the patient for 5 minutes absolutely does not pass muster with CMS and if you do it in large enough batches you'll either get away with it or return a looooot of money/fired
Click to expand...
No way. My job isn't done just because they get whisked away to cath. I still have to write a note, usually talk to at least the hospitalist, often update family, etc.
 
AlmostAnMD said:
You bill 35 min for a patient in ed less than 30 minutes?

Also fraud. I literally. Literally. Just got back from conference where this very issue came up. You thinking about the patient for 5 minutes absolutely does not pass muster with CMS and if you do it in large enough batches you'll either get away with it or return a looooot of money/fired
Click to expand...

No it isn't. You get to bill for talking to family, doing research, writing charts, calling people etc. If a STEMI comes in and leaves in 20 minutes, I'm not charting during that time. I'm managing the patient, making phone calls etc. I chart afterwards. That isn't fraud.
 
Nocturnist you really ought to come back at the conclusion of this and give a generic run down of what happened. Not that I can’t see the ending from here.
 
I spend about 10 minutes of time on a typical STEMI including diagnosis chat with cardiologist, documentation, and talking with family. So I almost never bill CC time on these. I get more RVUs per minute doing a level 5 in 10 minutes than a level 5 + critical care in 30 minutes.
 
I have been told by multiple billing companies that you can NOT bill critical care if they are not actively caring for them. If they are in the ED for 35 minutes then you can massage it a little that you were actively taking care of them. But if they were in the ED for 20 minutes, there is no physical way you were actively caring for them. Talking to family, charting, thinking about what to do when they left the ED does not count towards this.

I may be wrong but this is what I have been told multiple times. I almost never chart critical care because I rarely spent more than 30+minutes actively taking care of the pt. If I was allowed to count thinking about it, talking to consults, charting, talking to family then I could critical care literally every sick pt.

The guy/gal who obviously is overcharging Critical care could easily said he spent 2 hrs thinking about it. I mean, why not if this counts towards Critical care.

I just googled it and AI just spit out

No, you cannot bill critical care in the ED if the patient is not in the ED for at least 30 minutes. Critical care codes 99291 and 99292 require a minimum of 30 minutes of dedicated care to be billed. This time must be spent actively providing critical care services, such as managing a critically ill or injured patient.
For example, if a patient is in the ED for 25 minutes and then transferred, you cannot bill critical care. However, if the physician spent 35 minutes actively managing the patient's critical condition in the ED, then 99291 would be the appropriate code
 
Last edited:
thegenius said:
No it isn't. You get to bill for talking to family, doing research, writing charts, calling people etc. If a STEMI comes in and leaves in 20 minutes, I'm not charting during that time. I'm managing the patient, making phone calls etc. I chart afterwards. That isn't fraud.
Click to expand...
I don't think this is correct. If this is the case then every sick pt is critical care. Charting = 10 minutes. Thinking =10 minutes. Calling consult =10 minutes. talking to family =10 minutes. Actively taking care of a STEMI = 3 minutes.

This is in no way critical care.
 
Rendar5 said:
I spend about 10 minutes of time on a typical STEMI including diagnosis chat with cardiologist, documentation, and talking with family. So I almost never bill CC time on these. I get more RVUs per minute doing a level 5 in 10 minutes than a level 5 + critical care in 30 minutes.
Click to expand...
This is also incorrect. You spend more than 10 minutes doing this. You can also easily justify that it takes more than 10 minutes to do so. Just because the burger flippers could argue you could do it faster, I can easily argue that sound medical care easily takes longer. It only takes you 10 minutes to take care of someone experiencing a heart attack? Ask a lay person what they think. Your door to door salesman takes longer with far less impact on society. You also do not get level 5 patients routinely out of the ED within 10 minutes. This is a fallacy of extrapolation.
 
emergentmd said:
I have been told by multiple billing companies that you can NOT bill critical care if they are not actively caring for them.
Click to expand...
emergentmd said:
If this is the case then every sick pt is critical care.
Click to expand...
You can most definitely bill critical care for time spent on a patient. Actively caring for a patient includes documentation. It includes reviewing records. It includes discussing with alternative sources. It includes consultation and care planning. That is ‘actively caring.’ It doesn’t mean the patient has to be physically under your touch or in your department still. I’ve discussed this extensively with billing companies and leaders of billing in our speciality. Every ‘sick’ patient is critical care. That’s what we do. Get paid for what you do.
 
Mount Asclepius said:
This is also incorrect. You spend more than 10 minutes doing this. You can also easily justify that it takes more than 10 minutes to do so. Just because the burger flippers could argue you could do it faster, I can easily argue that sound medical care easily takes longer. It only takes you 10 minutes to take care of someone experiencing a heart attack? Ask a lay person what they think. Your door to door salesman takes longer with far less impact on society. You also do not get level 5 patients routinely out of the ED within 10 minutes. This is a fallacy of extrapolation.
Click to expand...
It’s not that much of an exaggeration for the average stemi coming in from EMS. It takes me literally one to two minutes to get a history, 30 seconds to put in orders, two minutes to write the chart, 60 seconds to talk with the cardiologist. another 30 seconds to tell a patient you’re having a heart attack and we’re gonna get this taken care of. That’s it. I’m done. Sometimes if I’m interested, I might take two minutes to read the cat report afterwards, but I don’t usually have time because I’m seeing 3-4 patients an hour some nights.

I actually love these cases because of how little time I need to spend on them.
 
Mount Asclepius said:
You can most definitely bill critical care for time spent on a patient. Actively caring for a patient includes documentation. It includes reviewing records. It includes discussing with alternative sources. It includes consultation and care planning. That is ‘actively caring.’ It doesn’t mean the patient has to be physically under your touch or in your department still. I’ve discussed this extensively with billing companies and leaders of billing in our speciality. Every ‘sick’ patient is critical care. That’s what we do. Get paid for what you do.
Click to expand...
I know you can bill Critical doing this and it is considered active. But you are not allowed if they are not in the ED. Once they are out of the ED, these are not considered actively caring for a critical pt b/c they are not under your care anymore.

Because if you are allowed to after they leave, then you can have essentially unlimited critical care time. Just be a slow documenter. Spend 60 minutes meticulously charting would be legal? Of course not.

Again, if Cc time was appropriate after the pt leaves, then every sick pt could be critical care when we all know they were not.
 
Rendar5 said:
It’s not that much of an exaggeration for the average stemi coming in from EMS. It takes me literally one to two minutes to get a history, 30 seconds to put in orders, two minutes to write the chart, 60 seconds to talk with the cardiologist. another 30 seconds to tell a patient you’re having a heart attack and we’re gonna get this taken care of. That’s it. I’m done. Sometimes if I’m interested, I might take two minutes to read the cat report afterwards, but I don’t usually have time because I’m seeing 3-4 patients an hour some nights.

I actually love these cases because of how little time I need to spend on them.
Click to expand...
That is the actual time we all spend on STEMI.


But people can game the system as much as they want when the pt is in the ED such as slow charting. But when they are out of the ED, this just doesn't fly.
 
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