Why do some critical care visits deny?
If critical care is billed the same date of service as a procedure, the services represented by the critical care charges must go above and beyond any evaluation and management efforts normally included in the surgical procedure. When critical care exceeds the work included in the surgery and the patient is critically ill requiring the constant attendance of the physician, providers bill the critical care code(s) with modifier 25. Additionally, the Centers for Medicaid and Medicare Services specifically require for critical care to have a diagnosis different from the diagnosis for a procedure done the same date. Therefore, without an appropriate modifier and different diagnosis reported on the initial claim submission, critical care charges the same date as a procedure will edit to deny. Coverage for critical care and a procedure sharing the same diagnosis might be allowed at the Appeals/Redeterminations level with appropriate documentation submitted. A patients medical records should
