ED Coding and Reimbursement Alert

Question: A patient who had heart surgery Monday is in the hospitals intensive care unit. The unit calls the ED physician Tuesday morning, when the patient suffers acute respiratory failure. The physician provides 66 minutes of critical care for the patient. How do we code for this, being that the ED physician did not perform the initial surgery?

Massachusetts Subscriber

Answer: Youll be able to report the critical care even though it occurs in the global period of another procedure -- just make sure to append the proper modifier to the code, and to include a diagnosis code that specifies what illness your physician is treating.

On the claim, report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the physicians service with 518.81 (Acute respiratory failure) appended. The 518.81 code is vital to this claim, as it shows that the ED physicians services were in no way related to any followup care for the patients heart surgery.

Modifier: There is no exact modifier that accurately captures services the ED physician provides in the global period of another procedure or surgery. Therefore, the modifier will depend on the payer. Some will want you to submit 99291 with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) appended, even though it states by the same physician in the descriptor. Others will prefer modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to show that it is a separate service from the heart surgery. Check with your carrier if you are not sure which modifier it wants in this situation. Many carriers will pay the claim without a modifier, especially if the two providers are from separate groups.