Billing Critical Care - message from Trillium

Hi Everyone,

Just wanted to touch base with you all to let you know that we have noticed a push back from MOH with regards to critical care codes. They are often returning these claims questioning the legitimacy of the codes and whether or not the correct codes were used. They are often asking us to provide documentation to prove that it was indeed critical care and that the number of units billed was also correct. Once we provide the documentation the claims are then approved, provided the documentation matches what was billed.

By returning these claims on an Error Report asking for documentation, there is a certain percentage of doctors that will never resubmit the claim which saves them money. Others will provide the documentation but if not documented correctly, MOH can reduce the amount paid or even deny the G codes altogether. Then it is up to the provider to request a lesser code instead. Again, hoping that the doctor will not resubmit.

Although we see this across all our clients who submit critical care codes, we noticed that it happens more often when three doctors are submitting for the same patient on the same day, something that happens quite frequently with your group at Victoria Hospital. We wanted to reach out to you today to ensure that you were aware that you could be asked at any time to provide documentation for MOH for a critical care visit and to remind you to be sure you document these visits properly in case that claim is questioned.

Remember, not every claim is questioned, just a random selection. Could be a new Claims Assessor or a Claims Assessor who notices a large number of critical care claims for a particular provider. Whatever the reason, they have the right to ask for documentation for any claim at any time.

You should know when to bill the G521 vs the G395, for example. I have provided a copy of the description of both for you below for your convenience. Is it really a G521 or should it be a G395 or even H1_2 ?

Your start and stop times should be recorded in your notes and if non-consecutive, remember to provide times for each unit. It is harder to provide documentation a month later than to document at the time of the visit.

A copy of the ER chart is not sufficient as it is rarely clearly documented. If we request documentation it needs to be the medical chart with times and the Injury Severity Score calculation included, if eligible.

Trillium takes every step to ensure these claims are paid properly but we need your help by providing the documentation when necessary.

This might be a good topic for your next group meeting.

If you have any questions, please let me know. We’re here to help.


Susan Dittmer, Partner
Tel: 905-336-2887
Fax: 905-336-9072

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