ED Coding and Reimbursement Alert

Your ED physician and a different specialty doctor can provide critical care on the same calendar date to the same patient during the same session -- as long as the services are not "duplicative."

"To me, -duplicative- would be two physicians from different specialties providing the same type of treatment," says Catherine Brink, CMM, CPC, CMSCS, president of Healthcare Resource Management in Spring Lake, N.J.

When coding for concurrent care, "the medical specialists may be from the same group practice or from different group practices," according to transmittal 1530, which provides an easy-to-access resource for Medicare's critical care coding guidelines, and also spells out CMS rules for coding concurrent care.

But both physicians cannot report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the same "hour" of care.

"Only one physician may bill for critical care services during any one single period of time, even if more than one physician is providing care to a critically ill patient," according to the transmittal.

Medicare may cover concurrent care by more than one physician (generally representing different physician specialties) if the requirements listed in the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, section 30E and this transmittal are met, confirms Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.

For instance, if a physician and an ED physician provide critical care services that warrant both physicians- expertise (such as congestive heart failure), then medically necessary concurrent critical care for the same date may be payable. Diagnoses can lend to the necessity of each specialist's service. Each physician reporting critical care time for a given date should identify the primary condition he is managing on the claim form.