ED Coding and Reimbursement Alert

Question: Encounter notes indicate that the ED physician performed 43 minutes of critical care and cardiopulmonary resuscitation (CPR) on a patient. Can we report the CPR separately from the critical care?

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Answer: You can report the critical care and CPR together — but that presumes that the encounter involved a minimum of 30 minutes caring for a critically ill or injured patient, which might not be the case. Check out the two scenarios below for more advice on reporting CPR and critical care for the same patient in the same session.

If the ED physician spent at least 30 minutes providing critical care outside of the CPR administration, then you should report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the critical care with 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 or other service) appended to show that it is a significant, separately identifiable service from the CPR. Then, report 92950 (Cardiopulmonary resuscitation (eg, in cardiac arrest)) for the CPR. Good notes will be important to tell if the critical care exceeded 30 minutes.

If the ED physician spent less than 30 minutes providing critical care outside of CPR administration, then it’s not considered critical care for coding purposes. In these cases, you should report 92950 for the CPR and 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) for the ED evaluation and management (E/M) service. Keep in mind clearly documented critical care of less than 30 minutes is instructed by CPT^® to be reported as 99285. Since critical care is in the E/M section of CPT^®, don’t forget to add modifier 25 to indicate the E/M and CPR were separately identifiable services; further, your critical care note should state that time spent providing critical care was net time spent providing any non-bundled procedures.

Even though the patient had a critical illness or injury, you can’t report 99291 unless that critical care surpasses 30 minutes. If you do report 99285 with 92950, be sure to list 92950 first, as it pays better than any code in the 99281-99285 set.

The 99291 code ($213.83) however, pays better than 92950 ($182.31), so you should list it first if the visit qualifies for critical care.