EM Coding Alert

Errors in notes can cost you one service.

If you’re coding for both an E/M visit and a critical care service on the same day, by the same physician, for the same patient, you’ll need to glean the medical necessity from the chart before reporting both codes. Without medical necessity, payers will deny part of your claim.

Learn from the experts how to get paid for both the critical care and the E/M by working with your physician to create strong notes.

Submit Same Day E/M and Critical Care

There is a possibility that your physician could perform an inpatient hospital or office/outpatient E/M service for a patient on the same date she performs a critical care service on the same patient. At the time of the E/M service earlier in the day, the patient may not have needed critical care. 

 “You can bill for an E/M service that was provided on the same calendar day as critical care in the hospital,” says Catherine A. Brink, BS, CMM, CPC, CMSCS, president of HealthCare Resource Management Inc. in Spring Lake, N.J. You’ll use 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (... each additional 30 minutes [List separately in addition to code for primary service]) to report the critical care service. 

Official wording: CMS states in Chapter 12 of the Medicare Claims Processing Manual that, “When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical care services and the previous E/M service may be paid on the same date of service.” Keep in mind to place modifier 25 on the appropriate service. To read the entire CMS document, visit www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf.

Watch out: Some payers may require that you add 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) to the non-critical care E/M service, says the American College of Emergency Physicians (ACEP) in their critical care FAQs (www.acep.org/Physician-Resources/Practice-Resources/Administration/Financial-Issues-/-Reimbursement/Critical-Care-FAQ). Others may not. “CPT® does not require the use of modifier 25 when billing for critical care services and separately billable (non-bundled) procedures,” the ACEP Website explains. You should ask your payers about their guidelines.

Example: An established patient comes into your office to see his doctor for a checkup on his hypertension. The physician performs an expanded problem-focused history and examination and finds no need for a change in medication. She documents that the patient is doing well. The physician performs medical decision-making of low complexity. For this scenario, you would code 99213, says Betty A. Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD, director, ICD-10 Development and Training at the AAPC in Salt Lake City.

Later that day, the patient is involved in a motor vehicle crash and is taken to the hospital in critical condition. He receives one and a half hours of critical care before he stabilizes and is admitted. “The critical care would be billed with 99291 and +99292,” Hovey adds.