ED Coding and Reimbursement Alert

When a patient presents with a serious injury or medical condition, ED coders should be on the lookout for critical care services the physician might provide. After all, these codes sport higher relative value units (RVUs) than standard E/M codes.

But be careful you don't miscode a claim in your zeal to use the high-RVU critical care codes. You-ll have to prove that the patient needed critical care services before considering 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) or +99292 (... each additional 30 minutes [list separately in addition to code for primary service]), or you-ll likely receive a denial for your claim.

According to CPT, a patient must be critically ill or injured for critical care services.

Translation: "A critical patient is the one you stop whatever else you were doing to go see ASAP. They are so sick that if you don't intervene, they will get worse or die," says Michael Lemanski, MD, ED billing director at Baystate Medical Center in Springfield, Mass.

According to Lemanski, examples of possible critical care scenarios include patients:

- with acute myocardial infarction, especially those requiring thrombolysis

- requiring intubation

- with respiratory failure from acute pulmonary edema, chronic obstructive pulmonary disease (COPD), etc.

- with hypertension that requires treatment

- who are unresponsive due to overdose, stroke, seizure, etc.

- with bacterial meningitis or status epilepticus.

Consider this example from Michael Granovsky MD, CPC, FACEP, president of MRSI, an ED coding and billing company in Woburn, Mass. A 67-year-old patient with COPD presents to the ED in severe respiratory distress with an acute exacerbation of his underlying lung disease. Despite multiple rounds of nebulizers, steroid treatment and additional supplemental oxygen, the patient develops worsening respiratory distress and ultimately suffers a respiratory arrest and requires intubation.

The physician documents that she spends 45 minutes outside of separately billable procedures caring for this critically ill patient.

On the claim, you would report the following:

- 99291 for the critical care

- modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99291 to show that the critical care and intubation were separate services

- 31500 (Intubation, endotracheal, emergency procedure) for the emergency intubation

- 799.1 (Respiratory arrest) and 491.21 (Chronic obstructive bronchitis; with [acute] exacerbation) linked to 99291 and 31500 to prove medical necessity for the encounter.

As shown in the above example, some services are separately reportable from critical care, says Jamie Darling, CPC, coder at EA Health Corporation in Solana Beach, Calif.

In addition to CPR, here are the other services that you can report separately from 99291 and 99292:

- endotracheal intubation

- pericardiocentesis

- EKG interpretations

- central venous catheter placement.

However, these services are bundled into 99291 and 99292:

- interpretation of cardiac output measurements

- interpretation of pulse oximetry

- interpretation of data stored in computers

- transcutaneous pacing

- ventilator management

- some vascular access procedures

- gastric intubation.

Suppose you-re looking at encounter notes indicating that the physician provided critical care. During the session, the physician performed EKG interpretations and pulse oximetry. On the claim, you should report the EKG separately, but you should consider the oximetry work part of the critical care.

Remember that critical care encounter time does not need to be continuous, says Rebecca Parker, MD, FACEP, president of Team Parker LLC, a coding, billing and compliance consulting firm in Lakewood, Ill. Also, with most carriers, the ED physician does not have to document each start and stop time for the critical care.

This makes coding for the service easier, since the physician might provide critical care to the same patient more than once over the course of the day. When he does this, just add up the total critical care minutes and code based on that time, Parker says.

Example: The ED physician provides 45 minutes of critical care for a patient in the morning. The patient's condition stabilizes, and the physician tends to other patients at the facility. Later that afternoon, with the patient's condition deteriorating, the ED physician returns to provide 20 more minutes of critical care. In this instance, the physician provided 65 minutes of non-continuous critical care. On the claim, report 99291.