ED Coding and Reimbursement Alert

Question: I have a debate with our biller regarding   how to bill Critical Care codes when multiple providers are involved. At our larger hospital we code and bill for the ED physician, the hospitalist and the physicians in critical care unit. My scenario is the following:  The patient arrives in the ED and requires 30 minutes of critical care services and then the care is later transferred to a hospitalist that provides 40 minutes of critical care services. How would each separate group code for those service? I say they both code 99291 because they are separate groups. The biller feels the ED physician should report 99291 and the hospitalist should report their services utilizing 99292. Please help.

Answer:  Two providers of the same specialty, in the same group, providing the same E/M service on the same day, for the same patient are deemed to be the same provider so the first hour of critical care would be reported with 99291 and subsequent units of 99292 would be reported by the second provider as appropriate.

If two physicians are of different specialties and different groups (often defined as different departments or different tax ID #s) have the same scenario, both would report 99291 for the first hour of critical care they provide. 

From the CMS Transmittal 1548:

The  CPT® code 99291 is used to report the first 30-74 minutes of critical care on a given calendar date of service. It should only be used once per calendar date per patient by the same physician or physician group of the same specialty.  CPT® code 99292 is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care

Clinical Example of Correct Billing of Time: 

A patient arrives in the emergency department in cardiac arrest. The emergency department physician provides 40 minutes of critical care services. A cardiologist is called to the ED and assumes responsibility for the patient, providing 35 minutes of critical care services. The patient stabilizes and is transferred to the CCU. In this instance, the ED physician provided 40 minutes of critical care services and reports only the critical care code ( CPT® code 99291) and not also emergency department services. The cardiologist may report the 35 minutes of critical care services (also  CPT® code 99291) provided in the ED. Additional critical care services by the cardiologist in the CCU may be reported on the same calendar date using 99292 or another appropriate E/M code depending on the clock time involved.