ED Coding and Reimbursement Alert

Question: A patient reports to the ED with critical injuries to her abdomen and chest; she was in an auto accident, and the ED physician cares exclusively for this patient for 98 minutes. During the encounter, the physician spends eight minutes inserting a peritoneal trocar and needle into the umbilicus, sending saline into the peritoneal cavity to check for intra-abdominal bleeding and infection; he then drains and collects the fluid. The physician also spends another five minutes ordering and interpreting a two-view frontal and lateral chest x-ray. Should I code the needle procedure and xrays separately, or are these part of the critical care package?

Arkansas Subscriber

Answer: Code the peritoneal lavage your physician performs separately and be sure to subtract out the eight minutes spent performing the procedure. The x-rays,however, are included in the critical care package. On the claim, report the following:

- 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-

74 minutes) for the first 74 minutes of critical care

- +99292 (- each additional 30 minutes [List separately in addition to code for primary service]) for the critical care beyond the first 74 minutes

- modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99291 and +99292 if the payer requires it (some payers want to see the modifier, though some do not)

- 49080 (Peritoneocentisis, abdominal paracentisis,or peritoneal lavage [diagnostic or therapeutic]; initial) for the lavage

Remember: After subtracting the eight minutes for the lavage from the overall encounter time, you have 90 minutes of critical care.

Also note that the only services that are bundled into 99291 and +99292 are:

- Interpretation of: cardiac output measurements(93561, 93562); x-rays (71010, 71015, 71020); pulse oximetry (94760, 94761, 94762); blood gasses; and information data stored in computers (such as ECGs,blood pressures, and hematologic data [99090])

- gastric intubation (43752, 91105)

- temporary transcutaneous pacing (92953)

- ventilatory management (94002-94004, 94660,94662)

- vascular access procedures (36000, 36410, 36415, 36591, 36600).