ED Coding and Reimbursement Alert

Question: Our physician recently coded a critical care service using the time spent with the patient to select the code. However, our coding team reviewed the medical record, and we don’t think the patient’s condition warrants this level of care or meets the requirements for administering critical care. We want to code the report with 99285 instead. Any suggestions as to whether we can, or should, code for a different service than the physician chose to perform?

Wyoming Subscriber

Answer: If you believe you have a strong reason to question the necessity or length of the critical care time your physician provided, you should probably review the patient record with the ED physician. You should then select the correct code based on the decision that you make in concert with the doctor.

Before you review the chart with the physician, make sure you know exactly why you are aiming to downcode the visit to 99285 (Emergency department visit for the evaluation and management of a patient …).

In addition, you’ll want to double check the critical care guidelines. Remember that a patient’s condition may qualify for critical care even if the danger isn’t currently life threatening to the patient’s health. Many coders get tripped up on that nuance. The guidelines state that a critical illness or injury is one that “acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration.” Therefore, even if your patient isn’t in a life-threatening situation but the possibility is likely, then your physician can typically bill for critical care. 

Check the guidelines for other details, including critical care time and other services provided during that time, to ensure that you’ve qualified for the service and that the service meets the threshold for the amount of time you’re using to drive the code selection.