Description
Hospital emergency department services are not payable for the same calendar date as critical care services when billed for the same beneficiary, on the same date of service and by the same service provider (based on Tax ID and Provider Specialty Code).
Affected Codes
99281, 99282, 99283, 99284, 99285
Applicable Policy References
1. SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Claims Processing Manual: Chapter 12- Physicians/Nonphysician Practitioners, §30.6.9 - Payment for Inpatient Hospital Visits – General
8. Medicare Claims Processing Manual: Chapter 12- 30.6.9.1 - Payment for Initial Hospital Care Services and Observation or Inpatient Care Services (Including Admission and Discharge Service)
9. Medicare Claims Processing Manual: Chapter 12- §30.6.12 (for dates prior to 5/9/2021) – Critical Care Visits and Neonatal Intensive Care (Codes 99291-99292), Section (H)- Critical Care Services and Other Evaluation and Management Services Provided on Same Day and Section (I) – Critical Care Services Provided by Physicians in Group Practice(s)
10. Medicare Claims Processing Manual: Chapter 12 – 30.6.12 (for dates after 05/09/21) – Critical Care and Neonatal Intensive Care (Codes 99291- 99292) (Effective 01/01/22; Implementation 02/15/22)
11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
12. CPT Manual