ED Coding and Reimbursement Alert

The ins and outs of critical care coding are difficult to discern without some concrete examples to illustrate 99291 scenarios. So what does a really detailed clinical scenario for critical care look like?

We asked Greer Contreras, CPC, senior director of coding for Marina Medical Billing Service Inc. in California. She gave us two samples.

The challenge: Look at these case studies and see if you can get all the codes -- diagnosis (ICD-9) and procedure/service (CPT) -- right:

A patient presents to the ED with worsening shortness of breath (SOB); the physician examines the patient and discovers elevated blood pressure and tachycardia. The physician orders a Cardizem drip to control the patient's heart rate; she then orders labs, a chest x-ray, and an electrocardiogram (EKG).

The physician performs multiple re-evaluations, interprets both the x-ray and EKG, and diagnoses congestive heart failure and atrial fibrillation. Total encounter time is 50 minutes; the EKG interpretation takes the physician four minutes.

Answer: On the claim, report the following:

• 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the 46 minutes of critical care;

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99291 to show that the critical care and EKG were separate services, if your payer requires it;

• 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) for the EKG;

• 428.0 (Congestive heart failure, unspecified) appended to 99291 and 93010 to represent the patient's heart failure;

• 427.31 (Atrial fibrillation) appended to 99291 and 93010 to represent the patient's atrial fibrillation; and

• 786.05 (Shortness of breath) appended to 99291 and 93010 to represent the patient's symptoms.

Caveat: "Do not report the chest x-ray interpretation separately as it is included in the critical care time," reminds Contreras.

A patient presents to the ED with dyspnea and wheezing; the history portion of the exam reveals the patient has asthma. The physician finds the patient in respiratory distress with retractions and accessory muscle use. He orders labs, a chest x-ray, an EKG, and an ABG (arterial blood gas).

The patient receives three rounds of Albuterol and Atrovent Nebs, and steroids by mouth. The physician performs multiple re-evaluations, interprets the x-rays, EKG, and ABG. The patient begins having markedly increased difficulty breathing during one of the re-evals, and the physician places the patient on BiPAP (bilevel positive airway pressure). Despite the BiPAP, the patient's rapid deterioration continues.

The ED physician intubates the patient and admits him to the intensive care unit (ICU). Final diagnosis is asthma and acute respiratory failure. The physician documents 110 minutes of encounter time with the patient; the physician spent five minutes on intubation and five minutes interpreting the EKG.

Answer: On this claim, you should report the following codes:

• 99291 for the first 74 minutes of critical care;

• +99292 (... each additional 30 minutes [List separately in addition to code for primary procedure]) for the remaining 26 minutes of critical care;

• modifier 25 appended to 99291 and +99292 to show that the critical care and the other procedures were separate services (if the payer requires it);

• 31500 (Intubation, endotrachael, emergency procedure) for the intubation;

• 93010 for the EKG interpretation;

• 518.81 (Acute respiratory failure) appended to 99291, +99292, 31500, and 93010 to represent the patient's respiratory failure; and

• 493.90 (Asthma, unspecified) appended to 99291, +99292, 31500, and 93010 to represent the patient's asthma diagnosis.