ED Coding and Reimbursement Alert

Know what to ask the doctor for improved 99291 claims
 
Coming up short when coding for critical care services (99291 and 99292)? More often than not, the culprit is insufficient documentation. Keeping exact track of time and resources expended - often difficult in your standard ED - is essential to correct critical care claims.

"We see cases that could be critical care yet can't be billed, because the time is missed or the documentation just isn't enough to support the selection of the critical care code," says Caral Edelberg, CPC, CCS-P, president, chief executive officer and founder of Medical Management Resources, a TeamHealth Company. Know Critical Care When You See It The first step to correctly reporting 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (... each additional 30 minutes) is to identify patients who are "critically ill" or "critically injured." According to CPT, "critical" illnesses and injuries are conditions that "acutely impair one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition." A critical care situation involves a physician with the highest level of preparedness intervening urgently to stop a patient's condition from becoming far worse.

Time flies when the ED physician is performing life-saving services, so check the documentation for signs of at least 30 minutes spent administering critical care services.

Remember: You can't include separately billable procedures in the time calculation. Also, the physician must attend exclusively to that patient during documented time for a service to qualify.
 
Example: A patient who presented with chest pain receives evaluation when she suddenly collapses. The ED physician quickly orders CPR and intubates. After he resuscitates the patient, he checks her medical history and obtains additional information through conversation with the patient's husband. The physician then aggressively treats the patient with intravenous nitroglycerin and lidocaine. After review of a chest x-ray for tube placement, the ED physician consults with the patient's oncologist and her family.

Total time of the encounter: 90 minutes, 60 of which were spent attending to the patient and providing critical care services after she had collapsed and after performing the two separately billable procedures (intubation and CPR).

In this instance, you would code a level-five visit (99285) since the physician performed a "comprehensive" E/M service. Report 31500 (Intubation, endotracheal, emergency procedure) and 92950 (Cardiopulmonary resuscitation) for the intubation and CPR.

You should report the 60 minutes of post-collapse treatment with 99291 and append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to this code to show that it was a separate service from the 99285. [...]