Consequences of "overbilling"

[Student3322]

I see a lot of variety in critical care billing practices. For example, I see some docs are routinely billing critical care time for anyone in the ICU even if stable and going to floor or home that day or totally hemodynamically stable just there for q1h glucose checks for DKA with insulin gtt.

Is it recommended to just err on the side of billing for critical care and if it doesn't meet criteria the coders or insurance company will just change it to non-critical care? If lots of physicians in a hospital are "overbilling," are there any consequences for individual doctors or is it just the hospital will get some consequences from CMS?

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[psychbender]

From what's been explained to me, billers can downgrade your charge if it fails to meet the burden, but they cannot upgrade your charge if you do meet it, but didn't code it. If you're on the fence, err on the higher charge, and let the bullets decide.

That having been said, I also notice several of my colleagues billing 99291 for some cases I would have just done 99233, as the patient didn't check any of the definite boxes for CC time, and overall didn't seem really sick enough for the unit. A DKA on IV insulin with a low BHB and mildly open gap is borderline, and I tend to code 99233. A colleague of mine says anyone on IV insulin automatically gets 99291 from him. *shrug*

 

[grt398]

It may be part of why CMS has decided to propose a large cut to CC billing by merging 99291 + the first unit of 99292. See here: Urging Changes to Proposed Critical Care Billing Policy - American College of Chest Physicians

But for you as an individual doc, just do what you think is right and can defend in your documentation.

 

[chessknt]

It may be part of why CMS has decided to propose a large cut to CC billing by merging 99291 + the first unit of 99292. See here: Urging Changes to Proposed Critical Care Billing Policy - American College of Chest Physicians

But for you as an individual doc, just do what you think is right and can defend in your documentation.

CMS did that to cut costs. It would be fantastic to see them cutting from one of the top 10 paid specialties first instead of burned out pandemic 'heroes' but **** us I guess.

 

[The kitchen sink]

CMS did that to cut costs. It would be fantastic to see them cutting from one of the top 10 paid specialties first instead of burned out pandemic 'heroes' but **** us I guess.

Can you surmise what the heck they were thinking? What about actual board certified critical care physicians billing this? Could they not have made an exemption for that? I don't get it.