EM Coding Alert

Hint: Intubation isn’t bundled into 99291 and +99292.

When patients report to the emergency department (ED) with a potentially critical illness or injury, certain questions will arise surrounding the scenario that will have to be answered in order to code the claim correctly.

Examples: Does the visit qualify for critical care, or should I report an ED evaluation and management (E/M) service instead? What services can I report separately in addition to the E/M care? How do I choose a diagnosis code for this patient?

Failure to miss the mark on even one of these questions can send your claim askew. Check out this detailed case study of a seriously (perhaps critically) ill patient, and see if you can code it correctly.

The Case

A 67-year-old with a known nut allergy was rushed to the ED after eating pasta with pesto sauce, which, unbeknownst to them, includes pine nuts. Within minutes, they experienced severe facial and throat swelling, difficulty swallowing, and body itching. Their partner reported that the patient’s breathing became increasingly labored as they made their way to the hospital, and the patient was eventually unable to talk and appeared to be gasping for breath.

Upon arrival, the emergency physician immediately recognized the need to protect the patient’s airway and administered etomidate as a sedative and rocuronium as a paralytic. The patient was intubated with a #4 Mac blade and a 7.0 mm cuffed tube. The procedure was successful; a chest X-ray confirmed that the endotracheal tube was in the correct position.

Following anaphylactic shock protocol, the patient was given intramuscular epinephrine, oxygen therapy, IV fluids, corticosteroids, and antihistamines. After treatment, the patient returned to their baseline condition and was extubated by the emergency physician. They were observed for several hours and maintained adequate oxygenation on room air without recurring symptoms. The patient was deemed stable for discharge, with no further hospital observation or admission required for further workup and treatment.

The emergency physician documented 39 minutes of critical care time, excluding the time necessary to perform the intubation.

On the claim report:

• 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the critical care
• 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 99291 to show that the ED evaluation and management (E/M) service led to the intubation
• 31500 (Intubation, endotracheal, emergency procedure) for the intubation
• T78.05XA (Anaphylactic reaction due to tree nuts and seeds, initial encounter) appended to 99291 and 31500 to represent the patient’s condition.

99291 explanation: The patient was critically ill and the visit exceeded 30 minutes — the two markers an encounter must clear before using 99291 and +99292 (… each additional 30 minutes (List separately in addition to code for primary service)). According to CPT^®, “a critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or lift threatening deterioration in the patient’s condition. Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.”

If this patient didn’t meet critical care requirements or the visit didn’t exceed 30 minutes, you’d have used an ED E/M code like 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) instead of 99291.

31500 explanation: According to CPT^®, intubation is not one of the services that is bundled into 99291 and +99292. Therefore, you should code it separately — but be careful to carve out the intubation time before settling on the total encounter minutes you might count toward critical care.

Chest X-ray explanation: The chest X-ray to verify correct tube placement is bundled into the critical care code and is not separately reportable. The services bundled into critical care are:

• Interpretation of cardiac output measurements (+93598)
• Pulse oximetry (94760, 94761, 94762)
• Chest x-rays, professional component (71045, 71046)
• Blood gases, and collection and interpretation of physiologic data (e.g., ECGs, blood pressures, hematologic data)
• Gastric intubation (43752, 43753)
• Transcutaneous pacing (92953)
• Ventilator management (94002-94004, 94660, 94662)
• Vascular access procedures (36000, 36410, 36415, 36591, 36600)

ICD-10-CM explanation: Although the patient presented with several symptoms that could have been coded individually, that step isn’t necessary since the ED physician reached a definitive diagnosis that was indicated by the patient’s symptoms. Therefore, you can code for the allergic reaction only, not the patient’s presenting symptoms.

If your physician hadn’t reached a definitive diagnosis, you would have coded each of the patient’s symptoms instead: severe facial and throat swelling, difficulty swallowing, body itching, and labored breathing.