ED Coding and Reimbursement Alert

Question: A very dramatic patient presented to the ED with intense stomach pain, diaphoresis, and a heart rate of 150. The physician spent 35 minutes in direct care with a seemingly critical case. Ultimately, after significant bedside care, the pain abated with a GI cocktail, and one of the final diagnoses was GERD in addition to chest pain and abdominal pain. Could we consider this a critical care case? Does the final diagnosis influence or determine the level of service we can report?

Minnesota Subscriber
 
Answer: First, to report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) or +99292 (... each additional 30 minutes [list separately in addition to code for primary service]), you need a statement from the ED physician that the patient's condition required more than 30 minutes of care and that she needed to provide interventions because of a high probability of imminent or life-threatening deterioration in the patient's condition to prevent a failing organ system (or rescue a failing organ system).
 
Ultimately, the final diagnosis is not the driving factor for selecting a critical care code. If the patient's vital signs were abnormal - and the presentation was consistent with a risk of failure of an organ system - or the physician's examination produced inconsistent data, then you would be justified in reporting critical care (assuming you had the doctor's statement of time spent), even if the final diagnosis included gastroesophageal reflux disease (GERD, 530.81).
 
Otherwise, you should report the appropriate evaluation and management code from among the following:

99281 - Emergency department visit for the evaluation and management of a patient, which requires these three key components: a problem- focused history, a problem-focused examination, and straightforward medical decision-making

99282 - ... an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity

99283 - ... an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of moderate complexity

99284 - ... a detailed history, a detailed examination, and medical decision-making of moderate complexity

99285 - Emergency department visit for the evaluation and management of a patient, which requires these three 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.