ED Coding and Reimbursement Alert

Tip: CC codes carry no caveat constrictions.

When you spot an encounter form that's a candidate for ED caveat coding, be sure you check if the patient received critical care, which pays out at a higher rate. Check out this quick critical care coding seminar, and ethically recoup almost $50 more each time you spot 99291 opportunities for patients who qualify for the caveat.

Check If Caveat Patients Got CC

Patients who qualify for the ED caveat often require critical care, confirms Michael Lemanski, MD, ED billing director at Baystate Medical Center in Springfield, Mass. "The caveat is used primarily for patients with altered mental status [AMS]," he says. " Although, a patient may be somnolent from something as simple as alcohol ingestion, many patients where the HPI is truly unobtainable have a life-threatening condition requiring critical care."

And there is a significant difference in payout between 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 ...) and 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).

By the numbers: 99285 pays about $169 per encounter (4.98 transitioned facility relative value units [RVUs] multiplied by the 2011 Medicare transition rate of 33.9764); conversely, 99291 pays about $218 per encounter (6.40 transitioned facility RVUs multiplied by 33.9764.)

When you see an ED caveat claim form, you should check to see if the visit qualifies for 99291 before choosing 99285, confirms Kathy Plato, CPC, director of coding education & credentialing at ebix, Inc., headquartered in Wisconsin. Only choose 99291 over 99285 if the caveat patient is critically ill or injured and the physician documents at least 30 minutes providing care for the patient outside of other procedures or services with a clear critical care attestation.

History Not Necessary for Critical Care

When you choose 99291 over 99285 for a patient that qualifies for the caveat, the HPI portion is not an issue.

Why? In contrast to standard ED E/M codes, critical care codes contain no specific history component -- though that doesn't make shirking HPI a good idea.

"Medicare's E/M Documentation Guidelines do not apply to critically injured or ill patients. However, it is good medical practice to document any limitations of history, or exam, from the patient's altered mental status," and document as much obtainable information as possible, Lemanski explains.

Example: A patient presented to the ED with altered mental status secondary to a head injury from a motor vehicle accident. According to the encounter notes, the physician was only able to obtain a "brief" medical history due to AMS. The physician intubates the patient and documents 45 minutes of critical care, For this claim, you should report 99291 even though the ED caveat applies.