ED Coding and Reimbursement Alert

These tips on documentation and what can be separately reported can save your life in audit situations

This life saving technique is often performed in the ED. Although it is not a time based code, time can be a big factor in your overall coding choice for these patient presentations. Read on to learn why.

CPR refresher: Cardiopulmonary resuscitation or CPR is performed when the patient’s heart and lungs suddenly stop functioning and immediate assistance is required to sustain life. CPR involves the provision of cardiac life support including chest compressions and ventilation of the patient. Although CPR can be performed anywhere, it is most often reported in the ED setting due to the emergency nature of the patient’s condition.

CPR vs. ACLS: Know These Clinical Differences

CPR is typically considered to be basic life support as opposed to advanced life support (ACLS), which involves the provision of drug therapy and possibly defibrillation. ACLS does not always require CPR and CPR requires some form of chest compressions and sometimes ventilation that are not a direct component of ACLS.

The physician does not have to physically perform the chest compressions or ventilation of the patient, but rather can direct the provision of CPR services while running a code, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, an ED coding and billing company in Bedford, MA.

CPT^® specifics: CPT^® states code 92950 (Cardiopulmonary resuscitation [e.g., in cardiac arrest]) is intended to describe restoring and maintaining the patient’s respiration and circulation after cessation of heartbeat and breathing.  CPR consists of assessing the victim, opening the airway, restoring breathing (e.g., mouth-to-mouth, bag-valve-mask, etc.), and restoring circulation (e.g., chest compressions), says Granovsky.

CPT^® goes on to say that “In most instances, CPR is performed prior to, with continuation during, advanced life support interventions, e.g., drug therapy and defibrillation, which would be included by reporting the appropriate critical care services code(s) from the E/M section of the CPT^® codebook”, but be mindful of the need to meet the 30 minute criteria net of separate procedures, Granovsky adds.

Factor in These Time-Based Elements

There are no specifically-defined documentation criteria for reporting CPR listed in CPT^®, but you’ll have to demonstrate medical necessity for the services provided and time spent can be part of that supporting information.

A procedure note stating that CPR was performed is helpful in identifying that it was performed, by whom and how long. CPR is not a time-based code and there is no mention of minimum or maximum amount of time spent performing and/or supervising CPR as being required to report CPR.

CPR + critical care: However, in the case when CPR is reported along with critical care 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), you’ll need to know how long CPR was performed so that that time may be deducted from the critical care clock. Be aware of the minimum time thresholds for code 99291 and make your code selection accordingly, says Granovsky. The bottom line with regard to CPR and critical care: You need 30 minutes of critical care time outside of any time the patient was receiving CPR.

Look for Accompanying Procedures

Similarly, CPR is a stand-alone code, but it can also be reported with other E/M services if the documentation supports both. Other procedures such as intubations or central line placement can also be reported in addition to CPR. An ED patient that requires CPR would typically be critically ill, but the circumstances may not justify reporting code 99291. Possible scenarios would be that the patient is transferred to surgery or expires before the 30 minute minimum time threshold for critical care, net of other separately billed procedures could be achieved. In that case, you may still report an ED E/M code if the documentation requirements are met. This may be a good example of appropriately invoking the level 5 acuity caveat. Don’t forget to append appropriate modifies such as -25 on the E/M code if required by your payer, advises Granovsky.

Let This Example Guide Your Coding

A 65-year-old patient is brought in by EMS with a witnessed ventricular fibrillation cardiac arrest. Cardiopulmonary resuscitation efforts are initiated immediately. Chest compressions are initiated, and respirations are supported with a bag valve mask. The patient remains in V- Fib and is shocked successively 3 times. Following the third shock the patient is in a more stable rhythm.

A 12 lead EKG is performed, interpreted by the emergency physician, and is consistent with a large acute MI.

The physician reviews a stat chest x-ray, labs including cardiac enzymes, and speaks with the primary care physician as well as gathering history from the family and EMS.

The on-call cardiologist is contacted and the patient is taken urgently to the cardiac cath lab. The physician documents a comprehensive history and exam.

On the claim, you would report

-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…).

-Append the 25 modifier to 99285 to show it is separately identifiable from the procedure

-92950 (Cardiopulmonary resuscitation [e.g., in cardiac arrest])

- 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only).