ED Coding and Reimbursement Alert

Question: A 22-year-old motor-vehicle accident victim reports with multiple injuries, and the ED physician provides 84 minutes of care to this critically injured patient. During this time the physician uses ultrasound imaging to place a femoral line (nontunneled centrally inserted venous catheter). Is the line placement separately reportable, or is it part of the critical care package? Idaho Subscriber Answer: You should carve the line placement service out of the total critical care time, because it is a separately reportable service. CPT 2008's Critical Care Services introductory notes list several procedures that are included in 99291 -- such as chest x-rays (71010, 71015, 71020) and cardiac output studies (93561, 93562). Placement of a femoral line is not on this list. Example: Let's say it took the ED physician 13 of those 84 encounter minutes to place the line. On the claim, you would report the following: - 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the 71 minutes of critical care (84 total minutes minus 13). - 36556 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older) for the femoral line placement - +76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular  needle entry, with permanent  recording and reporting [List separately in addition to code for primary procedure]) appended to 36556 for the ultrasound guidance. Check if your payer requires 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 the line.