ED Coding and Reimbursement Alert

Question: What are the guidelines for modifier use with critical care codes? For example, when the physician performed two hours of critical care, and we report 99291 and 99292, should we append modifiers? We don't report two units of 99292 because we've had too much trouble getting insurers to reimburse the second unit.

Virginia Subscriber Answer: The modifier that comes into play most often with critically ill patients is -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), because these patients frequently require multiple procedures. For multiple procedures on these patients, you would append modifier -25 to critical care code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).

Correct coding standards suggest that you shouldn't append -25 to code +99292 (... each additional 30 minutes [list separately in addition to primary service]), because CPT categorizes 99292 as an add-on code. And according to the manual's description, "All add-on codes found in the CPT book are exempt from the multiple procedure concept." However, some payers will require that you append the modifier to both codes.

Multiple units of 99292 frequently raise a payer's radar because it is uncommon for an ED physician to devote this much time to a single patient. Remember that when billing critical care for the ED physician, although the critical care time need not be "continuous," CPT does stipulate that the physician must devote "constant attention" to the patient during the time critical care services are performed.