ED Coding and Reimbursement Alert

What you need to know about a little-known, correct coding strategy

Although critical care codes are evaluation and management services themselves, there are some instances when you can code for critical care services and an additional ED E/M (99281-99285) on the same claim.

In the December 2006 CPT Assistant, -CPT clarified that an E/M and critical care may be reported when both are performed [in the same session],- says Jim Blakeman, senior vice president at Emergency Groups Office in Arcadia, Calif. However, to avoid denials, you are best served to include separate documentation for each service, experts say.

Consider this example, from Greer Contreras, senior director of coding for Marina Medical Billing Service Inc. in California:

A patient presents to the ED with epigastric pain with associated nausea and vomiting. The physician performs a comprehensive exam and takes a complete history, which reveals a negative cardiac history. The physician orders labs and an abdominal series. The radiologist reports the abdominal series as negative. The physician gives the patient IV narcotics and anti-emetics, and after re-evaluation the patient states she is feeling better. 

However, due to lingering clinical concerns, the physician arranges admission for further testing and serial abdominal exams.

While awaiting admission to an inpatient bed, the patient collapses. The physician starts CPR and intubates the patient. The patient is resuscitated quickly, is determined to have had an acute myocardial infarction (MI), and is started on nitroglycerin and lidocaine drips. Multiple re-evaluations are performed, as well as consultations with other providers. 

The physician spends 60 minutes of noncontinuous time (exclusive of the time spent supervising CPR and performing the intubation) tending to the patient after she collapses.
The patient is then admitted to the ICU for cardiorespiratory arrest.

The physician performed an E/M service and then had to provide critical care after the patient collapsed. In this scenario, Contreras says, you would:

- report 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) for the initial E/M

- link 789.06 (Abdominal pain; epigastric) and 787.01 (Nausea with vomiting) to 99285 to prove medical necessity for the E/M

- report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the critical care

- attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99291 to show that the critical care and E/M were separate services

- report 31500 (Intubation, endotracheal, emergency procedure) for the intubation

- report 92950 (Cardiopulmonary resuscitation [e.g., in cardiac arrest]) for the CPR

- link 427.5 (Cardiac arrest) and 410.9x (Myocardial infarction; unspecified site) to 99291, 31500 and 92950 to prove medical necessity for the critical care, intubation and CPR.

-A copy of the chart should be sent along with this claim,- Blakeman says, because some insurers will be reluctant to pay for 99291 and 99285. -Medicare, for example, will deny one of the services upon initial claim processing but will reverse the denial if you request a claim review and the chart supports the claim for both services,- he says.

While the E/M preceded the critical care in the above example, the E/M could also occur post-critical care, -when a medically necessary further repeat exam is done after the critical period has passed,- Blakeman says.

-It is quite common for a patient's presenting critical condition to resolve during the ED stay such that a separate decision can later be made as to whether the patient can safely be sent home rather than admitted,- Blakeman says.

The work of this separate decision (along with work associated with doing a reassessment and checking the final set of lab and ancillary studies) would warrant a separate E/M service, Blakeman says. However, be aware that while CPT rules allow reporting of critical care services regardless of whether the critical care precedes or follows the regular E/M service, Medicare will only recognize critical care and an E/M when the critical care follows a regular E/M service.

Best bet: Be prepared to appeal your claims that contain both critical care and E/M codes. You may not get fully compensated for these encounters the first time you file the claim, but extra effort on appeal should net you the rightful reimbursement.