OIG Targets Critical Care Services

The OIG has released a new audit report of critical care services.  The audit revealed a significant error rate and identified the following deficiencies:

  • Billing for critical care for patients whose condition did not support the need for critical care
  • Billing for critical care when the physician documentation did not support critical care services were rendered
  • Inadequate policies and procedures related to physician documentation of critical care
  • Inadequate coder education and training to ensure correct critical care coding 

Critical care services have been a long-standing coding risk area.  Critical care is routinely identified as one of the top services resulting in Part B overpayments.  The 2021 Medicare Fee-for-Service Supplemental Improper Payments Report reflected an 11.4% overpayment rate for critical care.  Physician reporting of critical care services is also a current OIG Work Plan item. 

To complicate matters further, CPT and CMS have different rules regarding proper time based reporting of critical care.

If you have not conducted recent auditing of your critical care billing, we recommend doing so at this time. Consideration should be given to the following:

  • Current utilization of critical care service codes
  • Adequacy of the documentation to support medical necessity for critical care
  • Adequacy of the documentation to support the provision of critical care
  • Adequacy of documentation and coding policies for critical care
  • Compliance with CMS versus AMA coding requirements as applicable
  • Education/training needs for clinical and coding staff

The experts at HBE are available to assist you with every aspect of your critical care documentation and coding.

The OIG report may be accessed here: https://oig.hhs.gov/oas/reports/region3/32000002.asp

The OIG Work Plan is located at: https://oig.hhs.gov/reports-and-publications/workplan/index.asp

CERT reports can be found at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/CERT-Reports

HBE’s team of coding and compliance experts is available to assist you with external reviews of your documentation, coding and reimbursement as well as providing customized education and training for your staff. We are also available to provide assistance with conducting risk assessments, internal investigations and policy and procedure development.  

DISCLAIMER:  This newsletter contains only summary information and highlights; it should be read in conjunction with the full article or document provided as a link.  Any advice or recommendations are general and specific questions should be directed to professional counsel.

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