Critical Care Plus: Bill for as Much Critical Care as You Deliver, Consultant Says 

Every day but the last should be considered as critical care 

By Julie Crawshaw, 
Critical Care Plus Editor

Many ICU physicians don’t get the reimbursement they deserve because they quit billing for critical care too soon, says consultant Frank Lucas, who has performed chart audits based on payer mix and midnight census of 100-150 records to assess potential revenues for more than 35 ICUs.

For example, if the patient is in the unit for six days, Lucas says that many physicians will quit billing for critical care when the patient begins to stabilize on the third or fourth day. Because physicians perceive the patient to be recovering, they deprive themselves of the $90 to $128 reimbursement differential between the billing codes for critical care and subsequent hospital visits.

Provided that physician spends 30 minutes per critical care patient per day excluding teaching and procedures, Lucas says ICU docs should bill for critical care for the first five days of that six-day stay, dropping to the subsequent hospital visit billing code only on the last day. "If you want to see patients who aren’t critically ill, go look on another floor," Lucas frequently admonishes the physicians for whom he bills. "Except for the day of discharge, you’re providing critical care, period."

Intensivists Make Money for Hospitals

Lucas owns Pittsburgh-based Physician Technologies, an ICU medical billing company that bills currently for six ICUs in which physicians have no office practices. He says intensivists have no reason whatsoever to under-bill, especially given the amount of money they make for the hospitals in which they work. He points to numerous studies that show that ICU patients under intensivist care recover more quickly, have fewer ventilation days and a lower rate of nosocomial infection than patients in nonintensivist care. Implementing intensivist care in an ICU usually lowers the average length of stay from 0.75 to one day per patient, which could translate into millions of dollars in cost savings for the hospital. "There’s a laundry list of about 34 areas in which various studies have shown decreased length of stay with intensivists that equates to big bucks," Lucas notes. And other than gerontologists, critical care physicians have the highest percentage of Medicare patients, which increases their chances of being audited.

Cost-savings are the number one reason hospitals employ intensivists, Lucas says. Medicare, Medicaid-type programs and most Blue Shields pay on a diagnostic related group (DRG) basis, so if a hospital will receive $7,000.00 for the DRG and needs to discharge the patient in nine days in order to make money, it begins to lose money on day ten.

Critical care is any hospital’s most expensive cost center, Lucas notes, yet trained intensivists are present only in about 10% ICUs nationwide. In the remaining 90% of hospitals, an average of four and a half consultants round on ICU patients daily only for the specific body problem their specialties cover.

"Hospital administrators in facilities that lack intensivists are frequently stunned to learn by how much intensivists increase the facility’s bottom line," Lucas says. "Most physicians are paid as fee for service and are actually incentivized to increase a patient’s length of stay, but intensivists are in partnership with the hospital." Even given that intensivists often receive "shortfall" subsidies, having one or more on board is a tremendous financial benefit. "A hospital that offers $200,000 annual shortfall payment may well be saving a million dollars because of the intensivists, and the net savings to the hospital is $800,000 not counting the better care for the patient," Lucas says. Contact information: Frank Lucas (412) 371-9831.