ED Coding and Reimbursement Alert

Question: My local Medicare payer has recently started denying critical care services, saying they are inclusive when billed with a procedure. The carrier sometimes pays only the intubation and discounts the rest of the visit. Should I report something differently?


Utah Subscriber
Answer: When billing critical care codes with procedure codes, be sure to append 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. Some payers, regardless of whether you append -25, will send prepayment audit letters asking for records to prove that the services for 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (... each additional 30 minutes [list separately in addition to code for primary service]) were indeed separate.

Make sure your physicians know that they need to dictate that they delivered "X amount of critical care time outside of separately billable procedures" on these charts. Certain carriers may be looking for that specific statement before they will pay for all the services on the claim.