ED Coding and Reimbursement Alert

Question: A patient reports to the ED with shortness of breath and requires intubation to protect his airway. The physician orders x-rays, labs and an electrocardiogram (EKG). He discusses the case with another physician, and they decide to admit the patient, who is diagnosed withrespiratory failure. The ED physician frequently checks on the status of the patient and writes admit orders. Total session time is 42 minutes. How should I report this encounter?

North Dakota Subscriber

Answer: This resembles a critical care scenario, though you'll need to double check to be sure that the physician provided at least 30 minutes of critical care to the critically ill or injured patient.

So if the total critical care time was at least 30 minutes, you should report the following:

• 31500 (Intubation, endotracheal, emergency procedure) for the intubation
• 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30- 74 minutes ...) for the critical care

Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99291 to show that the critical care and the intubation were separate services

518.81 (Other diseases of lung; acute respiratory failure) appended to 31500 and 99291 to represent the patient's respiratory failure

786.05 (Symptoms involving respiratory system and other chest symptoms; dyspnea and respiratory abnormalities; shortness of breath) appended to 31500 and 99291 to represent the patient's shortness of breath.

Exception: If encounter notes indicate that the ED physician spent less than 30 minutes providing critical care to the patient, you'll choose 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...) for the E/M service rather than 99291.

Of note: Chest x-ray interpretations are bundled into critical care but the EKG reading could be reported if the emergency physician provides the required separately identifiable written report. If you have documentation of an EKG, report it with 93010-26 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) for the ECG.