ED Coding and Reimbursement Alert

Question: A patient is brought to the emergency department (ED) in cardiac arrest. The ED physician performs cardiopulmonary resuscitation (CPR) in order to stabilize the patient, along with an appropriate history and examination. They also administered epinephrine for cerebral and coronary perfusion. Is the CPR or epinephrine separately reportable, or are they part of the ED evaluation and management (E/M) service?

Illinois Subscriber

Answer: You can report a code for the CPR and a separate code for the E/M service. The epinephrine administration, however, is part of the CPR.

On your claim, you should:

• Report 92950 (Cardiopulmonary resuscitation (eg, in cardiac arrest)) for the CPR
• Report the appropriate E/M code based on the encounter notes
• Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure) to the E/M code to show that the E/M and CPR were significant, separately identifiable services

Critical care question: When coding the E/M, you need to find out whether the ED physician provided critical care; if they did, you can report 99291-+99292 (Critical care, evaluation and management of the critically ill or critically injured patient …) for the E/M. If there was no critical care, then you should report the appropriate code from the 99281-99285 (Emergency department visit for the evaluation and management of a patient …) set.

Remember, the patient must have a critical illness or injury before you consider coding for critical care. “A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition,” according to CPT^®. The ED physician must indicate that they provided critical care in the notes — as well as how long the critical care lasted.

If the critical care lasted less than 30 minutes, you cannot report 99291-+99292 — even if the patient had a critical illness or injury. In those instances, you must choose the appropriate ED E/M code.

Payers are serious about enforcing the critical care time rule; if you submit any 99291-+99292 claims with less than 30 minutes of documented critical care time, expect a denial.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC