EM Coding Alert

Question: We had a patient with a history of angina report to the emergency department (ED) at 8 a.m. Thursday complaining of chest pain. Encounter notes indicate that the physician performed a level-four ED E/M service before discharging the patient with a diagnosis of acute angina. At 2:30 p.m. Thursday, the ambulance brought the patient back to the ED due to a myocardial infarction (MI). The same physician provided 49 minutes of critical care to the patient. Can we report both the early E/M service and the critical care?

Texas Subscriber

Answer: Yes. First, report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the critical care. Then, report 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity. …) for the visit earlier in the day. Attach 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 99291.

Here’s why: When the provider performs critical care and a separately reportable procedure during the same encounter, you must use modifier 25 on the critical care code to capture payment for both, says Jim Strafford, CEDC, MCS-P, principal of Strafford Consulting in the Bryn Mawr, Pa. The above scenario constitutes “two separate visits on same day, and it clearly justifies 99284 and 99291 — but that’s not a guarantee that every payer will go along with it,” Strafford says.

Best bet: Send as much documentation as you can that proves that the ED E/M service was truly separate from the critical care. While Strafford concedes that getting this type of documentation is a “pain” for coders, he says “but, it’s worth it to get paid for both codes.”