Critical care time fraud?

[valianteffort]

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'so long as the physician is immediately available to the patient' makes it seem like you can not bill for a STEMI after they have left from the department. This is from ACEP's page.

Critical Care FAQ

Critical Care FAQ

www.acep.org

 

[WhatJobDoIPick]

I don't bill 99291 for STEMI that's in department for < 30 minutes. The same goes for a code that I call on arrival or shortly thereafter.

The extra 2 RVUs just isn't worth it to me when someone can look at the record and clearly see they were in the department for < 30.

I'll settle for the 99285.

Now, if they're in the department for 30 mins and one second, I'm for sure billing it.

 

[thegenius]

I'm willing to change my behavior if we can just settle this debate

 

[WilcoWorld]

I'm willing to change my behavior if we can just settle this debate

I think the sticking point here is that you need to be on the unit where the patient is for your other time to count towards CC time. So, if the patient is in the cath lab (where you never go), while you're doing those tasks, you can't bill CC time for them

 

[johhnybgood]

I think the sticking point here is that you need to be on the unit where the patient is for your other time to count towards CC time. So, if the patient is in the cath lab (where you never go), while you're doing those tasks, you can't bill CC time for them

Can’t you just bill cc for 20 min. Helps support a level 5 chart.

 

[AlmostAnMD]

I'm willing to change my behavior if we can just settle this debate

It's definitely not a debate. One very misled person (similar to many I suspect), acting on advice from billers and his medical director (both of whom make money with CCT) insists this to be true. I have actual training on this and now work on the compliance/admin side of thing. A goddam lawyer that does CMS appeals (ie, he's ON the good guy side, trying to get the money recovered) actually gave the STEMI example provided as an actual example of fraud at a talk a few days ago.

Generally speaking, you can get away with it....the big money is insurance downcoding DRG payments as a back end denial or downgrading IP to OBS on the front end. These are things ED docs aren't even aware of. This can be swings of 30-40k/visit. CCT is just generally not worth independently investigating since the dollars recovered pales in comparison. It usually only gets looked at, as I previously mentioned, when other things are investigating and the investigators notice this when looking for something else.

It's important to remember....who taught you about CCT? The answer to 99% of you is going to be your billers/your boss/your peers. ACEP at least has it right in the image someone posted.

There ARE exceptions, but you can't just check a box that said you did 35 min of critical care time in a STEMI that rolled by in 11 minutes. You'd have to actually spell out what constituted that time. In general it's not advised.

Can’t you just bill cc for 20 min. Helps support a level 5 chart.

True. This is honestly the better use of it in this case.


"what you've been doing for years" does not mean legal...or advisable....it just means in the grand scheme it's never been investigated. There is a good chance you've done this for years, and may do it for many more....or, it gets caught. Just a gamble.

I think realistically absent other investigation not likely to be noticed, but in my mind it's not worth the risk, you shouldn't need RVU money so badly you can't make a mortage payment unless you put CCT on a stemi you blinked at.


EDIT: for clarity, when I was practicing I also did the same thing! started heparin, talked to cards, put 35 min down and walked away. I won't claim to be born all-knowing lol

 

[Mount Asclepius]

It's certainly a debate.

The ACEP Critical Care FAQ has some good information, but is not all encompassing. They publish the following disclaimer at the bottom:

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only. The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.

Different people have taken different interpretations when there isn't complete clarity. There is defensible ambiguity. To my knowledge, it is not spelled out anywhere in the CPT code 99291 (or addressed by AMA or CMS) that the patient has to be physically located in the Emergency Department for 100% of the critical care time. There are some rules you need to follow like not taking care of other patients, but that is separate. In my Utilization Management training I also haven't come across this.

I do completely agree that this is not what is typically being investigated. Anything can become caught up in an investigation. That doesn't mean it will result in a fine or negative action. I'm perfectly comfortable billing and defending that billing unless I receive better guidance to the contrary. People push the boundaries of critical care billing in other ways that I don't feel comfortable with doing, for example for toxic encephalopathy with a GCS barely less than 12 when administering sedation for agitated patients, minimal acute hypoxic respiratory failure of 88% receiving 2 lpm of supplemental oxygen, and borderline septic patients with a lactate of 2.2 without shock. I'm happy to defend billing critical care time for patients having heart attacks as to me that follows the true spirit of the definition and rules. The lowest threshold is that it has to pass the smell test. For the main topic at hand though, frequently billing over 180 minutes of critical care time doesn't.

 

[AlmostAnMD]

It's certainly a debate.

No.

It isn't.

You're just embarrassing yourself now. You saying its a debate is akin to me saying the sun will rise in the west tomorrow. "It's a debate."

I'm curious what your "utilization management training" was about. Did it happen to cover CFR 30.6.12.C? The federal regulation governing the latest revision of the CPT code book?

Here is a quote

From the effing regulation

The same regulation you apparently get to just make up in your own practice:

"Time must be spent either at the patients immediate bedside or elsewhere on the floor or unit as long as the physician is immediately available to the patient"


When you wink at the patient, admit them and bill 35 minutes of critical care time you are BREAKING. THE. LAW.

CPT99291 is not an imaginative, whimsical policy up for debate because you say so. I've tried to tell you CMS lawyers, which you are not, directly state it is fraud. I've tried to tell you, in my actual utilization training, which you definitely do not have, you are committing fraud. I've given you the Code of Federal Regulations explicit passage and word for word which unambiguously and factually states you are wrong.

You quoted an ACEP page. That's cute. I quoted the regulation they are summarizing.

"defensible ambiguity." Patient in ed for 11 minutes. You bill 35. Government says you commit fraud. Can you stand up and explain to the class what's ambiguous about a time difference of 24 minutes?

You're following the "true spirit of the definition and rules?" How about, you billed 35 minutes for an encounter that lasted 11, which is 100% opposite to what has been codified?

This is where we find out your real character, @Mount Asclepius . I was polite while you were spewing nonsense the first time. But even after someone posted an ACEP guide which, you didn't notice, lifts phrases out of the law itself then you choose to say "it's a debate." Are you going to admit you're wrong, or double down?

No, it isn't a debate. You cannot prove me wrong. You cannot cite a single resource to suggest otherwise, and mommy blogs don't count.

So tell me, are you ready to sit down and admit you know nothing? Because that's what actually happened here. The reality is someone told you to do something, you never questioned it, and now you're getting defensive without any substance of any kind to back it up. Just admit you're wrong and leave the topic.




What this does demonstrate is the hubris of people that just seem to make things up as they go. And when those people ignore multiple chances to back down they get taken to school.

For extra study, find some OIG reports where hospitals are forced to pay back money when caught doing exactly what you're doing. I'm done doing your homework for you now, do that part yourself. I'll give you a clue: the passage I cited is quoted extensively in them.

 

[Janders]

(1) the “i spoke with the family” time only counts when that is required for treatment decisions. So if you have a code you call after 10 minutes, and you thereafter spend 10 minutes talking to the family about their dead love one… doesn’t count. If you talk to them during the code, regarding treatment options.. it does count.
(2) charting counts. However the regs also state the patient needs to be accessible for you to care. So if you get a stemi out in 10 minutes and spend 21 minutes telling the family they had an MI and writing the most beautiful note… doesn’t count.

Now I do believe in common sense, so if a patient is in the ED 25+ minutes and clearly meet CC criteria and I spend time after they leave writing my note… I’m not combing the emr for precise arrival / depart times. I think we all know patients are often in the room a couple minutes prior to registration, and documented leave time can be off a few minutes. I’d be willing to face an audit of retrospective imprecise time stamps if I billed 32 minutes of critical care and the EMR says the patient was in the ED 29 minutes. No one expects us to carry stop watches.

But I wouldn’t want to defend a stack of 10 minutes STEMIs, personally. Or codes I called within 5-10 minutes of arrival.

A 10 minute code gets level 5 + pocus + cpr cpt + possible intubation if not done prehospital.

 

[Mount Asclepius]

No.

It isn't.

You're just embarrassing yourself now. You saying its a debate is akin to me saying the sun will rise in the west tomorrow. "It's a debate."

I'm curious what your "utilization management training" was about. Did it happen to cover CFR 30.6.12.C? The federal regulation governing the latest revision of the CPT code book?

Here is a quote

From the effing regulation

The same regulation you apparently get to just make up in your own practice:

"Time must be spent either at the patients immediate bedside or elsewhere on the floor or unit as long as the physician is immediately available to the patient"


When you wink at the patient, admit them and bill 35 minutes of critical care time you are BREAKING. THE. LAW.

CPT99291 is not an imaginative, whimsical policy up for debate because you say so. I've tried to tell you CMS lawyers, which you are not, directly state it is fraud. I've tried to tell you, in my actual utilization training, which you definitely do not have, you are committing fraud. I've given you the Code of Federal Regulations explicit passage and word for word which unambiguously and factually states you are wrong.

You quoted an ACEP page. That's cute. I quoted the regulation they are summarizing.

"defensible ambiguity." Patient in ed for 11 minutes. You bill 35. Government says you commit fraud. Can you stand up and explain to the class what's ambiguous about a time difference of 24 minutes?

You're following the "true spirit of the definition and rules?" How about, you billed 35 minutes for an encounter that lasted 11, which is 100% opposite to what has been codified?

This is where we find out your real character, @Mount Asclepius . I was polite while you were spewing nonsense the first time. But even after someone posted an ACEP guide which, you didn't notice, lifts phrases out of the law itself then you choose to say "it's a debate." Are you going to admit you're wrong, or double down?

No, it isn't a debate. You cannot prove me wrong. You cannot cite a single resource to suggest otherwise, and mommy blogs don't count.

So tell me, are you ready to sit down and admit you know nothing? Because that's what actually happened here. The reality is someone told you to do something, you never questioned it, and now you're getting defensive without any substance of any kind to back it up. Just admit you're wrong and leave the topic.




What this does demonstrate is the hubris of people that just seem to make things up as they go. And when those people ignore multiple chances to back down they get taken to school.

For extra study, find some OIG reports where hospitals are forced to pay back money when caught doing exactly what you're doing. I'm done doing your homework for you now, do that part yourself. I'll give you a clue: the passage I cited is quoted extensively in them.

I think if you watched a sunrise in the West you would feel less angry.

 

[emergentmd]

How does billing CCT when the pt is not even in the dept even pass the sniff test?

How can docs on one hand say that OP's EM charting was fraud but then bill CCT when the pt is not even in the dept?

It is essentially the same thing. Billing CCT when someone is not in the ED just doesn't pass the logic test. Someone in the ED for 30 min just doesn't qualify for 60 min CCT.

For so many docs to think that this is appropriate is astounding to me and lack of knowledge. You can argue gray areas but billing CCT when someone is not in the dept is not correct.

 

[Mount Asclepius]

Anyone ever respond to a code for a STEMI patient shortly after they have left the ED for the cath lab? Show of hands ✋ Is that being immediately available? Or is it better to say they left the department so they are no longer under my care. Good luck.

Should we keep all STEMI patients in the ED waiting for the cath lab team to show up from home just so we make sure that they are in the department when critical care time is performed? Our Cardiologists like to walk in with the patient ready. This helps ensure we meet the goal of 90 minutes. It’s also better patient care.

If we do better at our jobs by getting critically ill patients to potential life saving intervention faster should we be paid less?

I’m sorry, I forgot this isn’t a debate. Carry on with the usual programming. Although I suspect this thread is dead unless there is anything left to debate on the subject of if billing 300 minutes routinely is fraud.

OP, I don’t have anything else to add to your question other than I think it would be beneficial to address your concern with leadership.

 

[DocEspana]

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

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.

there are three elements: 1) you spent 31+ minutes on direct care WHICH INCLUDES care not spent in the room and "care" (charting, exclusive contemplation of the case, calls, family meetings) spent after the patient left. It just has to be truly effort spent just on that patient and has no direct relationship to the patients time in the ED, though obviously it does correlate 2) the final diagnosis needs to be life/limb threatening and 3) you need to have done SOMETHING about it that mitigated that life/limb threatening state somewhat.

parts 2 and 3 are why every abdominal pain isnt critical care even if they require a huge workup that takes a lot of time. even if you find something, in most cases it is not life limb threatening and even if it is, youre not doing much to mitigate that (diagnosing it for the surgeon doesnt necessarily count). The time required is, by far, the easiest of the three elements to accomplish.

 

[emergentmd]

there are three elements: 1) you spent 31+ minutes on direct care WHICH INCLUDES care not spent in the room and "care" (charting, exclusive contemplation of the case, calls, family meetings) spent after the patient left. It just has to be truly effort spent just on that patient and has no direct relationship to the patients time in the ED, though obviously it does correlate 2) the final diagnosis needs to be life/limb threatening and 3) you need to have done SOMETHING about it that mitigated that life/limb threatening state somewhat.

parts 2 and 3 are why every abdominal pain isnt critical care even if they require a huge workup that takes a lot of time. even if you find something, in most cases it is not life limb threatening and even if it is, youre not doing much to mitigate that (diagnosing it for the surgeon doesnt necessarily count). The time required is, by far, the easiest of the three elements to accomplish.

I have been told by almost all billing companies that care ends when pt leaves the ER. I understand charting, consults, talking to family members. Heck, you can be pooping and think about what to do could be considered CCT.

But when they are not in the ER, you are not allowed to continue CCT. If this was the case, every pt should be CCT that has a life threatening issue such as PE, AF, SVT, MI, etc.

I am sure I do not chart CCT enough but charting CCT when pt is not in the ED seems like a huge stress when you have no direct effect on caring for them anymore. Once they leave the ED, they are not your patient anymore even if you get called to the floor. Getting called to the floor is not part of ED care but now you are essentially a consult thus an inpatient charge.

 

[GatorCHOMPions]

Isn't this the whole point of having overly complex yet ambiguous billing/coding? Look at how we are squabbling over this stuff.

 

[AlmostAnMD]

I think if you watched a sunrise in the West you would feel less angry.

Or if I didn't post after going out drinking with a buddy of mine lol

This really is an area of, "you don't know what you don't know until you know what you don't know."

What makes it harder is that this really isn't policed actively so it allows for a lot of head canon until audit comes around, which just for this, as mentioned, is rare. But the dollar amount OP mentioned will definitely get paid back.


Regulations and rules are weird man. For any hosptialists out there, here's a fun trick I just learned to get patients to a SNF


Let's say someone has traditional medicare (A+B). They come in with mild uti, switch to PO abx next day and have other underlying things that make recovery slower but generally don't require IP care. So justifying IP to make SNF in 3 days isnt gonna fly.

This is like critical care time! You can make the geezer IP since unlike commercial payors IP decisions on Medicare aren't actively policed.

But they ARE audited more often by your states QIOs so that's a bigger gamble. And if they find people made inappropriately IP over i think 20% of reviews you get flagged for more frequent audits. So it's an honor system but it comes with caution to do right.

But let's say you reeeeally wanted that geezer IP to get him a SNF after 3 midnights. Heres how you do it:

1) make him an inpatient admission immediately

2) at the same time, issue him a HINN (hospital issue of non coverage, ie, hospital is not going to ask Medicare for payment and patient is responsible). HINN'd admissions don't count against you as they are not billing government

3) immediately tell patient or caregiver to appeal the HINN to their state QIO

4) profit!

For some reason, many systems have found out doing this results in the QIO siding with the the patient, meaning they tell you, the advisor/hospitalist, to overturn the HINN and grant full IP.

In other words the QIO, the body that does the auditing, tells you to make it IP because of the appeal but if you had done it on your own and got audited a year later it would have been flagged by the same organization!

Trick only works if they have a whiff of medical necessity. If it's just a custodial thing won't fly.

"MEDICARE HATES THIS ONE SIMPLE TRICK"

All kinds of weird stuff out there man. I'm constantly learning.

 

[DocEspana]

I have been told by almost all billing companies that care ends when pt leaves the ER. I understand charting, consults, talking to family members. Heck, you can be pooping and think about what to do could be considered CCT.

But when they are not in the ER, you are not allowed to continue CCT. If this was the case, every pt should be CCT that has a life threatening issue such as PE, AF, SVT, MI, etc.

I am sure I do not chart CCT enough but charting CCT when pt is not in the ED seems like a huge stress when you have no direct effect on caring for them anymore. Once they leave the ED, they are not your patient anymore even if you get called to the floor. Getting called to the floor is not part of ED care but now you are essentially a consult thus an inpatient charge.

I mean CMS and the AMA CPT disagree with those billers

ED Charting and Coding: Critical Care Time

ED Charting and Coding: Critical Care Time - Are you appropriately coding your Emergency Department charts for your critical care patients?

www.aliem.com

404 File or Page Not Found | College of Medicine – Jacksonville | University of Florida

The University of Florida College of Medicine – Jacksonville.

med.jax.ufl.edu

If you want the formal CMS wording on it, it basically is a more verbose version of what aliem and University of Florida have the state of this except they include a caveat that the physician should be available to the patient during the time billed, which is where some billers will sometimes argue patients off the floor no longer count. But most people interpret that as "you can't have gone home and count billing at home" not "patient is off the floor". Obviously I can see that ambiguity can exist.

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf&ved=2ahUKEwiNheX609KMAxXXSzABHfBZBnMQgMkKegQITxAQ&usg=AOvVaw2tKWOIHafucMiPRa86Ei3H

what was said before was probably right, its ambiguous to purposely hamstring us

 

[emergentmd]

Here is a read from your link. Looks like they agree a STEMI in the ED for a short period of time does not qualify thus was rejected for CCT. I know you can essentially do anything and call it CCT when pt in ER. But when they leave, it seems somewhat disingenuous, otherwise every sick pt can be CCT.

So if the same pt came to the ER for a STEMI and was in the ER for 15 min

Doc #1 - No CCT
Doc #2 - 35 min CCT b/c he charted after, discussed with consults, did a google search, etc.
Doc #3 - 75min CCT b/c he was a slow charter and was on hold with consults for 20 minutes after pt left ED.


Which is correct?

Revisiting the Case​

Let’s get back to our case of the patient presenting with a STEMI and a subsequent rapid disposition to the cardiac catheterization lab. Although that patient met the CMS critical care organ system dysfunction and high-risk for decompensation criteria, the provider spent less than 30 minutes of cumulative time on direct and indirect patient care. It is fairly rare that you are able to evaluate a patient, interpret all studies, and complete all documentation on a critical care patient within 30 minutes but it does happen. The patient’s chart was thus billed at a Level 3 visit (E/M code #99283).

 

[valianteffort]

Sounds like the solution for all of this is for the American Heart Association to change door to balloon time to 180 minutes to allow for 30 mins of patient time in the ER for an appropriate history, have the troponin return before activating the STEMI and to shave the groin area.

 

[end stage fibro]

This really is an area of, "you don't know what you don't know until you know what you don't know."

I am a physician advisor and agree with everything you’ve said in this thread. I agree with the quoted text so hard.

One quibble: most CDI programs I’m familiar with look at the ED chart only to find indicators to support a diagnosis. Having said that, if I were reviewing charts and found the same issue as in this thread, it would be a stat documented conversation with the EP. their director and CMO would be CCed. Odds are not toooo high that CMS will audit you, but if they do it sucks. A lot. For the whole hospital.

 

[DocEspana]

Here is a read from your link. Looks like they agree a STEMI in the ED for a short period of time does not qualify thus was rejected for CCT. I know you can essentially do anything and call it CCT when pt in ER. But when they leave, it seems somewhat disingenuous, otherwise every sick pt can be CCT.

So if the same pt came to the ER for a STEMI and was in the ER for 15 min

Doc #1 - No CCT
Doc #2 - 35 min CCT b/c he charted after, discussed with consults, did a google search, etc.
Doc #3 - 75min CCT b/c he was a slow charter and was on hold with consults for 20 minutes after pt left ED.


Which is correct?

Revisiting the Case​

Let’s get back to our case of the patient presenting with a STEMI and a subsequent rapid disposition to the cardiac catheterization lab. Although that patient met the CMS critical care organ system dysfunction and high-risk for decompensation criteria, the provider spent less than 30 minutes of cumulative time on direct and indirect patient care. It is fairly rare that you are able to evaluate a patient, interpret all studies, and complete all documentation on a critical care patient within 30 minutes but it does happen. The patient’s chart was thus billed at a Level 3 visit (E/M code #99283).

I mean their point was sort of the opposite of your argument. they are saying that the case in the example documented LESS than 30 minutes (20 to be exact), which is disqualifying for CC time billing. They do comment to make sure you're being honest, but their argument is that his documentation failed to support his claim not that he couldn't have claimed it or that his time with the patient wouldn't have counted (and they in fact include it as a common reason TO claim critical care). Their last point is about the fact that it is actually very common to qualify for critical care time, but because we decline to claim the 30+ minutes openly, we just leave it on the table.

I'm seeing my other two links didnt work. which is a shame. They were a UF question list on how to handle this exact question (and others about CCT billing) and the CMS packet itself on what it looks for. the UF one is explicit that they dont feel that the pt needs to be in the ED for the whole time, only that all of your work exclusively on the patient adds up to 30+. CMS is obviously wordy without being clear but its nice to see their exact phrasing and how nothing except for a vague statement that the provider must be available the entire time they bill seems to suggest anything about the patients ED time. Theyre both pdfs, i guess putting the link in didnt work.

 

[Rekt]

Just work nights and it solves the problem. Every stemi is in my department for >30 mins at night. It’s kind of a silly argument. I’ve had plenty of stemis I’ve had to intervene on. Ventricular dysthymias, bradycardias, rapid pulmonary edema, etc. and we bill CCT on much lower acuity garbage.

 

[Mount Asclepius]

Philosophically, one last add to this discussion without meaning to be argumentative. I just think it’s important when you step back and look at the forest. I agree with the concept of "you don't know what you don't know until you know what you don't know.” Hence, my foray into UM and CDI myself. I also think “a little knowledge is dangerous.” Just because some interpret rules a certain way doesn’t mean that’s fact. Rules and laws are often ambiguous. They can’t account for every scenario. There is an intent to a rule or law. Lawyers can debate. Rules and laws change. Over time you’ll see this happen a lot. As an aside, but important, I think some people are rule followers to a T where as others bend them (potentially appropriately) when there is ambiguity to fit what they believe. Sometimes people are right and sometimes not. There is a lot of risk-reward in life and everyone falls into what they feel comfortable doing. It’s arrogant to say that it’s black and white when it’s grey. I personally try to #1 do what’s right for each patient and #2 do what I can live with. Our system has a lot of issues and I have no problem billing what I think is fair when the rules are unclear and the system screws Emergency Physicians over - 2.83% Medicare cut, no increase in pay for inflation, PE/CMGs stealing contracts and skimming off the top, increased pressure to be the Everything Room, and the list goes on and on. Determine what you are comfortable with. No risk it, no biscuit. I don’t think critical care billing for every STEMI is risky, but some clearly do. I can live with a difference of opinion.

 

[Zebra Hunter]

Agreed, I’m certainly not going to lose any sleep billing critical care time on a frickin STEMI just because they were only in my department for 22 minutes.

We are getting nickled and dimed left and right from CMGs, hospitals, CMS, etc., and people are really picking over-billing CC time on a legitimate life threatening emergency as their hill to die on. Wild.

 

[AlmostAnMD]

We are getting nickled and dimed left and right from CMGs, hospitals, CMS, etc.

I'm not sure you or most people know how insanely true that is. Insurance has really upped their game by testing waters of finding ways, both legal and not, of not delivering payments.

The nickel-and-diming will only continue. Ultimately a physician's service is just an expense to them. In whatever way they can possibly reduce that cost as close to zero as possible they will try to do so.

The business side of medicine I'm still fairly new to. But I'm left with a general impression we are not human beings to them. Neither are patients. Both of us are populations that siphon off money their profits, and they'll do anything to decrease payments.

Unfortunately physicians are very much on the losing side of the equation here. Insurance owns congress. Hell, even the nursing lobby has influence there. Physicians? Like an island with a slowly eroding beach. The future isn't fun to think about for docs, we just weren't built, trained or supported to financially prosper when the pie starts to shrink (or expand for others).

 

[sloh]

As an aside, but important, I think some people are rule followers to a T where as others bend them (potentially appropriately) when there is ambiguity to fit what they believe. Sometimes people are right and sometimes not. There is a lot of risk-reward in life and everyone falls into what they feel comfortable doing. It’s arrogant to say that it’s black and white when it’s grey. I personally try to #1 do what’s right for each patient and #2 do what I can live with. Our system has a lot of issues and I have no problem billing what I think is fair when the rules are unclear and the system screws Emergency Physicians over - 2.83% Medicare cut, no increase in pay for inflation, PE/CMGs stealing contracts and skimming off the top, increased pressure to be the Everything Room, and the list goes on and on. Determine what you are comfortable with. No risk it, no biscuit. I don’t think critical care billing for every STEMI is risky, but some clearly do. I can live with a difference of opinion.

It's interesting to see the discussion unfold here and where physicians lie on the spectrum of "follows rules to a T" to "bends the rules" to "wanton fraud endangering patients." Meanwhile....

For more than a decade, the Pennsylvania doctor and his national empire of vascular clinics had been scrutinized by agencies at every level — state medical boards, the Food and Drug Administration, the Department of Justice — for conducting experimental or unnecessary procedures on patients, putting their lives and limbs at risk.

He’d been disciplined by medical boards in over a dozen states, lost privileges in multiple hospitals and settled federal allegations of fraud, admitting that his company had performed procedures without any documented need. Pennsylvania had tried to shut his clinics down. Just a few months ago, federal attorneys announced a case against him, claiming he put “profits over the health and safety of his patients” when performing invasive artery procedures, regardless of symptoms or need.

And yet, after all of that, McGuckin is still seeing patients today, still adding to the nearly $50 million he has earned in the past decade in federal insurance reimbursements.

Unstoppable: This Doctor Has Been Investigated at Every Level of Government. How Is He Still Practicing?

Medical boards, a health department and even federal investigators have scrutinized Dr. James McGuckin’s vascular clinics. Today he still practices, despite a decadelong string of sanctions, fines and lawsuits.

www.propublica.org

 

[Mount Asclepius]

It's interesting to see the discussion unfold here and where physicians lie on the spectrum of "follows rules to a T" to "bends the rules" to "wanton fraud endangering patients." Meanwhile....

Unstoppable: This Doctor Has Been Investigated at Every Level of Government. How Is He Still Practicing?

Medical boards, a health department and even federal investigators have scrutinized Dr. James McGuckin’s vascular clinics. Today he still practices, despite a decadelong string of sanctions, fines and lawsuits.

www.propublica.org

We’re all on the spectrum. Don’t be on the far end!

This is a byproduct though of when hospitals and insurance companies are for profit entities at the expense of physicians. Some physicians recognize that and savvily set out to do it themselves. Some lose sight along the way. The error is that while healthcare is a business, medicine is a science and healing is an art. Don’t forget the patient in the chase for more dollars. It’s much harder to scrutinize someone when they have the patient’s best interest at heart.

 

[EctopicFetus]

I tend to agree STEMIs are not CCT. I rarely bill CCT for them. I think there is some gray here. Immediately available is not exactly the same as in the ED. I also think this new billing rubric makes the “bill 20 mins to guarantee a level 5” less meaningful. Getting to a level 5 in an admitted patient is super simple.

Speak with cards, interpret the EKG, monitor or CXR. Note you can not bill the EM for the EKG AND use it here so the monitor is quite easy. On top of that I assume you ordered 3 tests (CBC, EKG, BMP, Trop, CXR etc). That is now overkill for the data portion of the level 5 chart. Admission gets you the risk part.. Forget the COPA.

So its easily a level 5..

There is definitely a bit of room between what someone considers CCT and others dont. I do believe in many ways your billing company should be the arbiter of what is acceptable.

If I document CCT on a simple lateral malleolus fx i expect my coders to be like WTF are you talking about EF.. we are gonna code this as a level 4..

 

[TeddyBoomBoom]

I feel I’m going against the grain here, but I gotta admit that:

EMS calls with STEMI alert (or they don’t)
I interpret EMS ekg (or wait till they show up.)
Pt with CP, pale, diaphoretic.
Gets aspirin.
ED EKG = heart attack
Activate cath lab.
Pt gets heparin.
Talk to cardiologist.
Txfr to cath lab.

^ Is CCT time for me every time, regardless of door to balloon time, or whatever.

I’m not trying to game the system, but i feel fairly confident that the above passes muster 🤷

 

[valianteffort]

I feel I’m going against the grain here, but I gotta admit that:

EMS calls with STEMI alert (or they don’t)
I interpret EMS ekg (or wait till they show up.)
Pt with CP, pale, diaphoretic.
Gets aspirin.
ED EKG = heart attack
Activate cath lab.
Pt gets heparin.
Talk to cardiologist.
Txfr to cath lab.

^ Is CCT time for me every time, regardless of door to balloon time, or whatever.

I’m not trying to game the system, but i feel fairly confident that the above passes muster 🤷

You’re going to jail Teddy is what I learned in this thread

 

[Rendar5]

I feel I’m going against the grain here, but I gotta admit that:

EMS calls with STEMI alert (or they don’t)
I interpret EMS ekg (or wait till they show up.)
Pt with CP, pale, diaphoretic.
Gets aspirin.
ED EKG = heart attack
Activate cath lab.
Pt gets heparin.
Talk to cardiologist.
Txfr to cath lab.

^ Is CCT time for me every time, regardless of door to balloon time, or whatever.

I’m not trying to game the system, but i feel fairly confident that the above passes muster 🤷

I don’t think anyone would argue that it is not CC time. It’s just not 30 minutes worth of CC time. unless I’m slow or there are ed complications.
Maybe 10% of my stemis amass 30 min of time. This is due to hypotension, intubation, arrhythmias, or delays in transfer to cath lab due to unforeseen situations (in which I’m reassessing every 5-10minutes and have more than one chat with cards or cath team).
The only time I ever think I amassed more than 30 minutes of critical care time for a straight forward quick case was when I was an accepting physician on a transfer from our sister hospital and started diagnosing, and arranging all care for the patient well before they arrived. Including contacting the cardiologist initially, and then when they left, and then updating them when they arrived. (Cath team was a couple minutes late so patient had to stop off in the ed instead of going g straight to catch)

 

[Janders]

Stemi is a tale of two cities.

Where I work? Community ED with no cath lab? Gotta call the tertiary center. Talk to nurse. Talk to fellow / attending 5-10 min later. Pull an ambulance. Tell the crew to move their asses when they get to me. Plus the standard history and exam and meds and xray. Patient is likely in my ed 40min before they leave. I’m walking by every 5-10 to check on them until they GTFO.

They are getting 30min of critical care every day and twice on sundays.

Stemi at the big hospital Ed where they stay in the ED literally 5-10min and are whisked to a cath lab?
I’m billing them 10min of cc and writing a level 5 chart.

 

[Mount Asclepius]

The only time I ever think I amassed more than 30 minutes of critical care time for a straight forward quick case was when I was an accepting physician on a transfer from our sister hospital and started diagnosing, and arranging all care for the patient well before they arrived.

Good point. If we can’t do critical care time once they’ve left the ED, we should start doing before they’ve arrived 😉

 

[HemorrhagicShock]

I'm pretty certain that the billing and coding system is so complex, so convoluted, so stupid that if I was a CMS auditor, I could likely find some aspect of fraud in any top 10% biller in any specialty across the United States.

Seeing you guys go back and forth over this BS is yet another reason why I'm glad I'm out; what a waste of time. Imagine thinking you'd be doing this excel-sheet-secretary-level trash when you decided to be an ER doc.

 

[ShockIndex]

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?

CMS has concluded its investigation of this emergency physician (pictured below) and determined that fraud is not the cause of the excessive critical care times….

 

[TooMuchResearch]

Checks out.

 

[Old_Mil]

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?

Is compensation in your ED RVU based?

 

[Nocturnist]

Is compensation in your ED RVU based?

I know the compensation is based on a base salary and there is a productivity bonus but beyond that I don't know any more details.

 

[ERMudPhud]

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.

Wow, so many questions. So they kept a subtoxic tylenol ingestion in the ED for 5 hours and then admitted it to the hospitalist after doing... ...nothing. Seems like a ridiculous use of resources not to mention the critical care fraud. Just cause the guy sat in your ER 5 hours waiting for his 4 hour level doesn't mean you spent 5 hours actively managing his critical illness. And unless there is a lot more to the story if his 4 hour level is below 150 send him to psych not medicine.

Charitably I'm guessing this doc was given a long list of diagnoses that qualify for critical care by his billing company and then either was told or misunderstood and decided to bill for the entire length of ED stay for those patients. Or maybe he built a dotphrase that automatically pulls in the length of stay when he types ".mycritcare" That would be stupid but I could see someone doing it. Going to get caught eventually. If a patient comes in with SVT and I give them adenosine I might bill critical care but if they can't get a ride home for 8 hours I'm not billing for 8 hours of critical care.

I typically document some random number of minutes between 35 and 60 minutes and then move on. A decent number of my charts are critical care but I don't think I've ever documented more than 2 hours ever on one patient and never more than 180 minutes in a shift. 40 hours in a ten hour shift must be several standard deviations beyond the norm. Outliers get noticed and pounded down. Do the hospital and the doc a favor and show the numbers to the ED director, CMO, and CEO.

Oh yeah for the MI to cath lab patients. I bill however many minutes they are in the ER. Figure it doesn't hurt to say critical care time of 12 minutes. If I leave it out I inevitably get a query from the coders about why I didn't bill critical care and then I have to explain that it was only 12 minutes. Easier to just put in the 12 minutes. If I leave it in maybe it gets me to a 99285 but I should be there anyway. For my rural sites nobody flies out in under 30 minutes and I'm usually pretty busy with them during that time.

 

[Nocturnist]

Wow, so many questions. So they kept a subtoxic tylenol ingestion in the ED for 5 hours and then admitted it to the hospitalist after doing... ...nothing. Seems like a ridiculous use of resources not to mention the critical care fraud. Just cause the guy sat in your ER 5 hours waiting for his 4 hour level doesn't mean you spent 5 hours actively managing his critical illness. And unless there is a lot more to the story if his 4 hour level is below 150 send him to psych not medicine.

Charitably I'm guessing this doc was given a long list of diagnoses that qualify for critical care by his billing company and then either was told or misunderstood and decided to bill for the entire length of ED stay for those patients. Or maybe he built a dotphrase that automatically pulls in the length of stay when he types ".mycritcare" That would be stupid but I could see someone doing it. Going to get caught eventually. If a patient comes in with SVT and I give them adenosine I might bill critical care but if they can't get a ride home for 8 hours I'm not billing for 8 hours of critical care.

I typically document some random number of minutes between 35 and 60 minutes and then move on. A decent number of my charts are critical care but I don't think I've ever documented more than 2 hours ever on one patient and never more than 180 minutes in a shift. 40 hours in a ten hour shift must be several standard deviations beyond the norm. Outliers get noticed and pounded down. Do the hospital and the doc a favor and show the numbers to the ED director, CMO, and CEO.

Oh yeah for the MI to cath lab patients. I bill however many minutes they are in the ER. Figure it doesn't hurt to say critical care time of 12 minutes. If I leave it out I inevitably get a query from the coders about why I didn't bill critical care and then I have to explain that it was only 12 minutes. Easier to just put in the 12 minutes. If I leave it in maybe it gets me to a 99285 but I should be there anyway. For my rural sites nobody flies out in under 30 minutes and I'm usually pretty busy with them during that time.

Psych doesnt admit at my hospital. But yeah, essentially I admitted for suicidality and a psych consult the next morning (and for repeat LFTs). Honestly i don't understand how something rises to the level of cc with normal vitals/labs and if your only intervention was a liter bolus and no calls to any consultant. But ya, I think we're all in agreement none of us ever billed 5 hours on anything, and certainly not a week's worth of a busy ICU's RVUs into a mediocre ER shift.

I did end up going to the ER director with my concerns first at ya'lls suggestion.

As far as i could tell nothing was done because the next week's shift together, said doctor billed at least 23 hours of cc time. So I took my concerns to my hospitalist director with specific patients and number of cc minutes.

As far as I know this doctor still works there but we haven't had another shift together yet so that's where it's at currently.

 

[southerndoc]

Oh yeah for the MI to cath lab patients. I bill however many minutes they are in the ER. Figure it doesn't hurt to say critical care time of 12 minutes. If I leave it out I inevitably get a query from the coders about why I didn't bill critical care and then I have to explain that it was only 12 minutes. Easier to just put in the 12 minutes. If I leave it in maybe it gets me to a 99285 but I should be there anyway. For my rural sites nobody flies out in under 30 minutes and I'm usually pretty busy with them during that time.

I also feel this is good practice to bill for critical care time <30 mins on some patients. If they ever audit your charts, it will support you not overbilling critical care if you also have a decent number of charts <30 mins since it reflects actual time spent on patient care.

 

[AlmostAnMD]

As far as i could tell nothing was done because the next week's shift together, said doctor billed at least 23 hours of cc time. So I took my concerns to my hospitalist director with specific patients and number of cc minutes.

other people said talk to director....myself I suggested vpma or cmo. This puts a stop to fraud quickly. There's a good chance the director doesn't understand or care. And now there's some evidence you know it's ongoing as well!

Like I said, directors are good for minor issues, not for major hospital-changing audits

 

[Mount Asclepius]

I also feel this is good practice to bill for critical care time <30 mins on some patients. If they ever audit your charts, it will support you not overbilling critical care if you also have a decent number of charts <30 mins since it reflects actual time spent on patient care.

Several have speculated on this concept and I’d love to know if anyone has any definitive information, perhaps from a prior audit/investigation. Couldn’t you just always argue that you know you can’t bill critical care for under 30 minutes so never bill critical care for patients that take less than 30 minutes? Who wouldn’t spend at least 30 minutes on a critically ill patient? If you average 2 pph average couldn’t you fairly easily also argue that you spend approximately 30 minutes on every patient? I just don’t see how having a number of charts less than 30 minutes really helps you. I think the argument you and others have made sounds reasonable in theory, but I question if it has actually ever come up and suspect people have more likely just left money on the table.

 

[BoardingDoc]

Several have speculated on this concept and I’d love to know if anyone has any definitive information, perhaps from a prior audit/investigation. Couldn’t you just always argue that you know you can’t bill critical care for under 30 minutes so never bill critical care for patients that take less than 30 minutes? Who wouldn’t spend at least 30 minutes on a critically ill patient? If you average 2 pph average couldn’t you fairly easily also argue that you spend approximately 30 minutes on every patient? I just don’t see how having a number of charts less than 30 minutes really helps you. I think the argument you and others have made sounds reasonable in theory, but I question if it has actually ever come up and suspect people have more likely just left money on the table.

I had a colleague who used to bill for less than 30 min of cc time when he thought it was appropriate. He got flagged by our billing company and they specifically told him to stop doing that.

 

[ShockIndex]

I had a colleague who used to bill for less than 30 min of cc time when he thought it was appropriate. He got flagged by our billing company and they specifically told him to stop doing that.

That seems a little weird. When I worked for EMP more than a decade ago we were encouraged to do it (when appropriate) under the previously mentioned logic that it supported a level 5 visit. Now, we do it in the ICU all the time due to the accumulation of CC time in a calendar day from providers in same speciality and group being cumulative.

 

[WilcoWorld]

I will regularly document under 30 min CC time, and my billers/coders have never said a word about it. I started doing it after @southerndoc (if memory serves) mentioned doing it, because, if I ever get audited it would be nice to be able to point out that I document CC time that I don't bill for, and so you have reason to trust the times that I do bill for.

 

[ERMudPhud]

I had a colleague who used to bill for less than 30 min of cc time when he thought it was appropriate. He got flagged by our billing company and they specifically told him to stop doing that.

You certainly can't bill for it. But you can chart it. If you tried to bill 99291 while only charting 12 minutes that's fraud. But if you chart that you spend 12 minutes in critical care that just factual reporting of what you did.

To the original poster. If you have exhausted everything up to and including the C-suite at your hospital and your own moral code allows it keep in mind that CMS pays whistleblowers for exposing fraud. Up to you. Charitably I'd like to think that the doc reporting 20-40 hours of critical care in a shift that only lasted 10 hours is naively following or misunderstanding some directions he was given by his supervisors or billing company but its still fraud.

 

[RustedFox]

a STEMI that out of department in less than 30 mins is 30 mins of CC time.

Time spent charting, thinking about charting, thinking about reading charting ... counts.

 

[Janders]

a STEMI that out of department in less than 30 mins is 30 mins of CC time.

Time spent charting, thinking about charting, thinking about reading charting ... counts.

Yet our actually subject matter experts upthread disagree. Charting counts if done “either at the patients immediate bedside or elsewhere on the floor or unit as long as the physician is immediately available to the patient". Charting once the patient is gone does not fit…

 

[RustedFox]

Yet our actually subject matter experts upthread disagree. Charting counts if done “either at the patients immediate bedside or elsewhere on the floor or unit as long as the physician is immediately available to the patient". Charting once the patient is gone does not fit…

I didn't see this post - but let's dissect it. Where's that actual language? Because I'm available as long as I'm in the hospital. I respond to floor codes, I've gone to the cath lab for intubations.