BACKGROUNDThe Medicare ProgramTitle XVIII of the Social Security Act (the Act) established the Medicare program, which provideshealth insurance coverage to people aged 65 and over, people with disabilities, and people withend-stage renal disease. The Centers for Medicare & Medicaid Services (CMS) administers theMedicare program. Medicare Part B provides supplementary medical insurance for medicaland other health services, including critical care services performed by physicians. CMScontracts with Medicare administrative contractors (MACs) to process and pay Part B claims.Medicare Coverage of Critical Care ServicesCritical care is defined as medical care delivered directly by a physician or a qualified nonphysicianpractitioner for a critically ill or critically injured patient. A critical illness or injury isone that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition. Critical care involves highcomplexity decision making to assess, manipulate, and support vital system functions to treatsingle or multiple vital organ system failure and prevent further life-threatening deteriorationof the patient's condition (HCPCS [Healthcare Common Procedure Coding System] and CPTCodebook 2016–2018, and CMS, Medicare Claims Processing Manual, Pub. No. 100-04,Chapter 12, § 30.6.12.A (the Manual)).The time that can be reported as critical care is the physician time spent engaged in workingdirectly related to the individual patient's care. That time must be spent either at the patient’simmediate bedside or elsewhere on the floor or unit as long as the physician is immediatelyavailable to the patient. When the physician is providing critical care services, he or she mustdevote his or her full attention to the patient and cannot provide services to any other patientduring the same period (HCPCS and CPT Codebook 2016–2018, and the Manual, Chapter 12,§ 30.6.12.C).Critical care is a time-based service. CPT code 99291 is used to bill for the first 30 to 74 minutesof critical care on a given date of service by a physician or physician group of the samespecialty. CPT code 99292 is used to bill for additional blocks of time of up to 30 minutes eachbeyond the first 74 minutes of critical care occurring on the same date. Critical care that is lessthan 30 minutes in total duration on a given date should be reported using another appropriateevaluation and management (E&M) code (HCPCS and CPT Codebook 2016–2018, and theManual, Chapter 12, § 30.6.12.F). See the Figure on the following page for an explanation ofhow to code critical care services according to the amount of time spent providing critical care.Medicare Requirements for Identifying and Returning OverpaymentsClinical Practices of the University of PennsylvaniaClinical Practices is the faculty practice group for the University of Pennsylvania PerelmanSchool of Medicine’s clinical departments. Clinical Practices has locations throughout thePhiladelphia, Pennsylvania, metropolitan area and includes physicians in 59 different medicalspecialties and sub-specialties. Clinical Practices operates as a University of Pennsylvaniadivision and is responsible for operating the Perelman School of Medicine faculty’s clinicalpractices, as well as other University of Pennsylvania Health System clinical practices. Duringour audit period, Novitas Solutions was the MAC that processed and paid Clinical Practices’claims.
PA,
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