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October 23, 2014 - Updated 01.12.16

Progressive Corrective Action (PCA) Review: Critical Care

The J15 Part B Medical Review department performed Progressive Corrective Action (PCA) reviews on critical care services throughout the year. The findings of PCA reviews occurring over 2015 are as follows:

  • The documentation did not support guidelines for Critical Care:
    • No time was documented
      • CPT codes 99291-99292 are time-based codes
      • The medical record must clearly reflect the time spent on the critical care service
      • CPT code 99292 reports each additional 30 minutes past the initial 30-74 minutes of critical care reported under base code, CPT code 99291.
    • The documentation did not support a life threatening illness, treatment of imminent decline/deterioration in the patient's condition.
    • The documentation did not support high level intervention by the provider.
  • The documentation failed to support the medical necessity of the service.
  • Signature guidelines were not met (missing, untimely, illegible).
  • Failure to provide documentation in response to the request for medical records.
  • When CPT code 99292 was billed in addition to CPT code 99291, and the base code was denied, the payment for CPT code 99292 was also recouped. CPT code 99292 is an add-on code to CPT code 99291, and is not covered without coverage of its base code, CPT code 99291.

For more information on Medicare guidelines, including documentation required to process a claim, please refer to:

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