Critical Care Plus: Reimbursement Requires Conveying Criticality

Capture all the elements, attorney says

The key points critical care physicians should remember when documenting for reimbursement is to be certain their reports capture the elements of the reimbursable service and convey that the care provided is indeed critical, says Paula Sanders, who chairs the Health Law Group at Wolf, Block, Schorr & Solis-Cohen LLP in Philadelphia.

Sanders says ICU practitioners sometimes submit pages of progress notes filled with data unbillable as critical care because the data of itself doesn’t convey that critical care is what’s being given. And the American Medical Association’s recent redefinition of critical care as urgent or life threatening, removing the word "unstable" from the previous definition, doesn’t make reimbursement documentation any easier.

Sanders says failing to document that the critical care physician has personally done a history and physical, even though these were recorded elsewhere in the hospital medical records on which the physician relied on performing services, can provide the carrier with grounds for recouping payments. She cites one of her cases in which a physician performed in-hospital, referral-based diagnostic tests, relying on his reading of the patient’s earlier H&P records. Nothing in his records indicated a health and physical exam had determined the test was medically necessary and the carrier recouped a substantial sum of money.

"Had he even documented his review of the medical records, the recoupment probably would not have been as large," Sanders says. "I think that’s where the critical care people get hanged as well."

Consults Susceptible to Reimbursement Denial

Reimbursement for consults, Sanders notes, can be particularly tricky. Failing to document for review of systems or history of present illness—or to document that more than 50% of the time was spent performing counseling and coordination of care—can cause the entire service to be deemed non-billable.

For example, when a patient with severe COPD consults a pulmonary specialist, the provider may bill at level five, which requires a complete review of systems, complete history, comprehensive examination, as well as high-level medical decision-making. If the pulmonary specialist includes only a pulmonary review of systems, it could drop the level of service reimbursed. But documenting the appropriate review of systems and noting that the remainder of systems are negative is acceptable if all the remaining systems were in fact reviewed.

Critical care physicians should be as descriptive as they can, Sanders notes. Outside auditors sometimes lack sufficient clinical background to understand the situation, and if they don’t understand it they may act as if it didn’t happen. "I haven’t seen this much in my practice, but it does occur," she says. "The more descriptive you are, the more it reflects how much was done for the patient."

Document what forms the basis of your opinion, not just what you concluded, Sanders says, thinking of documentation as you once did elementary school algebra when the teacher made you write down all the steps of your problem. And write legibly. Although some carriers are allowing physicians involved in audits to have their records typed, an easily readable handwritten record remains the best practice. Most auditors, Sanders notes, consider legibility a hallmark of good record keeping.

There is an inherent conflict between providing care and documenting it not so much to help other caregivers as to obtain reimbursement, Sanders notes. "The flip side of that," she says, "Is that if you legibly document what you do, other health care providers can better understand the patient’s condition." For more information, contact Paula Sanders at (215) 977-2398.