ED Coding and Reimbursement Alert

Question: There is confusion in our emergency department about billing for thrombolytics. Does Medicare pay for them? Should they be billed with critical care?

Florida Subscriber

Answer: Medicare does not pay for the physician work component of thrombolytics. But other payers do. When coding for a non-Medicare stroke patient who presents to the ED with myocardial infarctions, use 37195 (thrombolysis, cerebral; by intravenous infusion) and 92977 (thrombolysis, coronary; by intravenous infusion).

In most non-Medicare cases the physician will likely charge for critical care if thrombolytics are provided in the ED for those payers that recognize 92977 or 37195 with critical care (99291, critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and 99292, ... each additional 30 minutes). For Medicare, only the critical care and any additional billable procedure would be coded.

A physician can report critical care services (99291-99292) when a critically ill or unstable patient receiving TPA needs constant monitoring. Stroke patients also require a thorough medical history and CAT scan prior to receiving TPA to rule out potential side effects. Attach modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the critical care code when submitting claims to private payers. Use 92975 for intracoronary TPA for the cath lab only, not the ED. Sometimes ED doctors use 99291 if the procedure takes more than 30 minutes, but 92977 is not bundled with this critical care code. Typically, carriers recognize 92977 as the correct CPT code for the ED. EKGs and chest x-ray performed to aid in the decision to give TPA are not bundled with 92977.

Use 92977 for TPA no matter the brand: Retavase, Alteplase, TNK, etc. TPA is a life-saving treatment. Although it carries tremendous risk 5 percent risk of severe bleeding complication carriers will likely cover it.

Medicare only recognizes the critical care E/M code. Medicare policy on TPA states that the drugs can be administered in an outpatient setting prior to hospital admission. If TPA is administered in an outpatient setting and the Medicare patient is transferred to a more appropriate facility, payment for TPA is made under Part B outpatient services based on reasonable cost to the first hospital.

Codes reported on a UB92 indicate the level of resources used by the facility, but almost always the hospital admits a patient following TPA. This means treatment of Medicare patients received in the ED is bundled into the hospitals diagnosis-related group payment for the inpatient stay. The ED rarely receives Medicare payment unless the patient dies while being treated.