ED Coding and Reimbursement Alert

Question: The physician spent 41 minutes treating a patient with chronic congestive heart failure (CHF) who was in cardiac arrest. Of those minutes, 15 of them were spent performing cardiopulmonary resuscitation (CPR), and the rest were spent providing critical care to this critically ill patient. How should I report this encounter?

Massachusetts Subscriber

Answer: Although the patient was critically ill, and your physician provided critical care, you cannot report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for this encounter. You need at least 30 minutes of critical care to report 99291, and your encounter comes up just short.

Why? CPR is separately reportable from 99291, meaning you need to subtract the 15 minutes of CPR time. That leaves you with 26 minutes of critical care time, which must be reported with another ED evaluation and management (E/M) code.

On the claim, report

• 92950 (Cardiopulmonary resuscitation (eg, in cardiac arrest)) for the CPR
• 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) for the E/M service
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99285 to show that the CPR and E/M were significant, separately identifiable services
• I50.22 (Chronic systolic (congestive) heart failure) appended to 92950 and 99285 to represent the patient’s CHF
• I46.2 (Cardiac arrest due to underlying cardiac condition) appended to 92950 and 99285 to represent the patient’s cardiac arrest