ED Coding and Reimbursement Alert

If you're overwhelmed every time you have to decipher codes for anaphylactic patients, you need to learn which services CPT bundles with the critical care codes.

You can use critical care codes (99291-99292) for the treatment of anaphylactic shock, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. However, many ED physicians find it difficult to decide whether to categorize the services provided to anaphylactic-shock patients as critical care or an upper-level ED visit. Take a look at the following scenario to help clarify this complex issue for you. 

Suppose a 30-year-old woman is exposed to peanuts during lunch. She presents to the ED with mild symptoms of anaphylactic shock including itching and restricted breathing. While in the ED, she loses consciousness. Because the patient is unconscious and the physician has to perform cardiopulmonary resuscitation, you can bill critical care codes. This is appropriate because the woman's condition is life-threatening. As long as the time the physician spent performing critical care services is more than 30 minutes, you can use the critical care codes (99291-99292). Code 99291 corresponds to the first 30-74 minutes. Use 99292 for each additional 30 minutes. You should report any critical care less than 30 minutes with the appropriate E/M code.

When treating anaphylaxis, the ED physician will often need to perform many procedures, most of which you need to bill separately. Remember that you can bill separately for procedures not included in the critical care bundle, but you cannot include them in the time element of the critical care. Outside of the 30 minutes spent providing critical care, the physician performs CPR. The billing consists of two codes:

 99291-25 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes

 92950 Cardiopulmonary resuscitation.

Be aware of relevant services that you can bill separately from the critical care: 
 

 CPR (92950)
 

 31500 (Intubation, endotracheal, emergency procedure)
 

 Tracheostomy (31603, 31605)
 

 36489* (Placement of central venous catheter)
 

 chest tubes (32020)
 

 transcutaneous pacing (92953)
 

 arterial lines (36620)
 

 lumbar puncture (62270*).

You need to place modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the E/M service code when the physician performs other procedures on the same day that are not bundled in the critical care services. Also, if the physician performs more than one procedure, you should place modifier -51 (Multiple procedures) on the less expensive procedure. "Strict CPT teaches you that you need to put modifier -51 on the procedure performed in addition to the critical care or E/M service when there are more than one," says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, the president of Cash Flow Solutions Inc. in Lakewood, N.J. This is a controversial area, however, because modifier -51 was really meant for surgeons in the operating room performing multiple procedures during the same anesthesia and surgical session. Many coders omit    -51 for unrelated procedures and still receive reimbursement for each procedure. 

Understand that the patient's case may not always reach the critical care state. In many cases, epinephrine administration will resolve the problem before the patient enters a critical care state. If the physician had given this patient an injection and avoided the critical care state, you would bill only for the appropriate E/M code. Most carriers include injections in the E/M service code.