ED Coding and Reimbursement Alert

When scouring the notes for evidence of an ED caveat scenario, coders can easily forget to ask themselves one simple question: Can I report a critical care code for this scenario?

The answer's yes more often than you might think, says Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La.

"Many patients who qualify for the caveat may also be candidates for critical care. If the condition is severe enough that the patient's ability to provide this information is impaired, then the condition may be critical," she explains.

Considering critical care and the caveat simultaneously can make your head spin, as the ED caveat does not even apply to 99291 (Critical care, evaluation and management of the critical ill or critically injured patient; first 30-74 minutes) or +99292 (... each additional 30 minutes [List separately in addition to code for primary service]).

Why? "There are not the same bullet-counting requirements for documentation of history, physical examination, or MDM [medical decision making] for critical care," explains Edelberg. The descriptors for critical care concern only E/M of the critically ill or injured patient.

So when your physician invokes the ED caveat for a patient, check to see if the patient was critically ill or injured; if she was, and the physician documents at least 30 minutes of critical care, consider 99291.

Payout: The only level of service you can invoke the ED caveat on is 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...).

The 99285 code pays about $171 nationally (4.74 transitioned facility relative value units [RVUs] multiplied by the temporary 2010 Medicare conversion rate of 36.0846), whereas 99291 garners about $217 (5.99 RVUs multiplied by 36.0846).

We asked Michael Lemanski MD, ED billing director at Baystate Medical Center in Springfield, Mass., to describe a scenario in which the physician provides critical care to a patient who also qualifies for the ED caveat:

Emergency medical services (EMS) presents with two teenage girls that were involved in a high-speed motor vehicle crash with roll-over. One of the girls has been extricated, has a traumatic amputation of her left arm, and lost vital signs en route to the ED. The other has a head injury, is hypotensive, and appears too intoxicated to provide any history for either patient. The girl who lost vitals en route is clearly critically injured, but the only history available to the physician is when the collision occurred, where, and how. Details about past medical history, social history, family history and review of systems (ROS) are unavailable. The physician spends a total of 64 minutes providing critical care services for the patient.

Caveat achieved, but ...: In this instance, the ED physician could reasonably invoke the ED caveat - but it is unnecessary, as you should report 99291 for thisencounter.