Critcal Care

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Joined: Fri Sep 21, 2012 2:54 pm

Mon Feb 12, 2018 2:29 pm

I am working a denial of critical care by Humana Medicare for one of my pulmonologists. Patient was taken to Hospital A where their pulmonologist performed critical care. Due to no ICU bed availability, the patient was transferred to Hospital B where my pulmonologist performed critical care. Our CC charge was denied as "coverage/program guidelines were exceeded". I found a September 2017 presentation by Noridian with an example of two physicians, same specialty, different practices which stated both could bill critical care. I would like to have something from the Medicare Claims Processing Manual to send with this appeal. I have researched this for a couple of hours now, but every search takes me to two physicians, same group. I appreciate any help!!!
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Thu Feb 15, 2018 8:41 am ... SE1317.pdf

Please see the link inside the document above in regards to the necessary documentation when the patient is transferred between facilities. If everything was billed properly, and neither provider has privileges at the other facility, then it should provide you the steps to appeal.

This can occur, if Hospital A and B are the same TID, or the same group (i.e. A and B are the same company, two locations), if the providers that billed have privileges at A and B, or if A documented the patient as admitted, not discharged or transferred.

I hope this helps.

Your question has been answered by Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC
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