ED Coding and Reimbursement Alert

The keys are diagnosis codes, time-based documentation

When a patient becomes critically ill or injured during the global period of a procedure provided by another physician, you may be tempted to treat the patient and forget about coding for critical care, but this could be costing your ED justified reimbursement.

In many cases, the critical care is separately reimbursable, but the proper coding for this scenario depends on the carrier. With a little research, and an assist from the right modifier, you can rightfully code separately for critical care occurring during a global period.

Hernia Repair Followed by Critical Care

Example: A patient with non-reducible, right-sided inguinal hernia, CHF, and controlled type II diabetes comes to the hospital for a hernia repair. Three hours after the operation, the patient shows signs of shortness of breath, problems urinating, cyanotic extremities, and an irregular pulse.

The patient goes into cardiac/respiratory arrest, and the ED physician is called to the floor. The ED physician resuscitates the patient. The clinical bedside care involves a brief period of CPR and intubation/ventilation.

The patient stabilizes after 48 minutes of care outside of any separately billable procedures such as CPR and intubation.

In this scenario, you should be able to bill for the critical care using 99291 (Critical care, evaluation and management of the critically ill or injured patient; first 30-74 minutes). However, on first pass, some payers may mistakenly deny the critical care service because it occurred during the global surgical period of 90 days for the initial hernia repair.

Contact Payer Before Choosing Modifier

Even though the ED physician may have no relationship with an initial treating surgeon, some payers will want modifier 24 (Unrelated E/M service by the same physician during a postoperative period) on the claim, says Marie West with Medical Data Services in Edmund, Okla.

However, other carriers may prefer modifier 25  (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for critical care provided during the global surgical package. Check with your insurer before filing the claim to see which modifier it requires.

For instance, Cigna Medicare asks you to use modifier  25 for critical care on the same date as a procedure.

Which Diagnosis Codes Are Appropriate?

You should use an ICD-9 code between 800.0 and 959.9 (except 930-939) with critical care codes, says Noridian Administrative Services in its latest provider question-and-answer file. These diagnosis codes will clearly indicate that the critical care was unrelated to the surgery, Noridian says.

-Any serious, unexpected, adverse event after surgery that meets the CPT definition of -critical- would work, as long as it had nothing to do with the reason for the surgery,- says Dianne Wilkinson, the compliance officer and quality manager for MedSouth Healthcare in Dyersburg, Tenn.

Don't overlook: The critical care codes need documentation to support the severity of the illness as well as the complexity of the physician's decision-making, says Jennifer Swindle, senior coding consultant with PivotHealth in Nashville, Tenn. You should document in detail all the time the physician spent.