Gastroenterology Coding Alert

In the March Gastroenterology Coding Alert article Initial Hospital Care Codes: Documentation and Decision-Making Key to Correct Coding on page 21, it was implied that no other evaluation and management (E/M) service could be reported on the same day as the initial hospital care codes (99221-99223). While it is not advisable to bill for more than one site of service (hospital, office/outpatient or emergency room) E/M visit on the same day, critical care codes (99291-99292) can be reported on the same day as a site of service visit.

In most instances, one evaluation and management code per day is appropriate, says Janet Leineke, CCS, CPC-H, senior outpatient consultant for Laguna Medical Systems, a health information management consulting, outsourcing and education services company headquartered in San Clemente, Calif. But there are situations where it is appropriate to report more. A site of service E/M visitwhere the gastroenterologist is asking questions about the patients medical history as well as doing a comprehensive examinationis a distinctly different type of service (and therefore, separately reimbursable) from what occurs during critical care. With critical care, the gastroenterologist may be required to be present at the bedside or in the critical care unit to assist in stabilizing a patient with internal bleeding. This might include lavaging through an NG tube or monitoring resuscitative orders.

Use Modifier -25 With Hospital or Outpatient Code

A patient may be admitted to the hospital early in the day using one of the initial inpatient care codes (99221-99223) and then become critically ill at some point, according to Leineke. In that situation, gastroenterologists should bill an initial care code with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached in addition to the critical care code.

Both Medicare payment policy and CPT coding guidelines agree that critical care codes can be reported on the same day as either hospital or outpatient E/M codes. According to section 15508.F of the Medicare Carriers Manual, if there is a hospital or office/outpatient evaluation and management service furnished early in the day and at the time the patient does not require critical care, but the patient requires critical care later in the day, both critical care and the evaluation and management service may be paid.

The critical care also can occur before the hospital services are provided. An article in the December 1998 CPT Assistant explains that [c]ritical care services can occur before the hospital care services are provided. In this instance, it would still be appropriate to report both the critical care service codes(s) and the appropriate level of E/M code for the same physicians services provided later in the day.

Emergency Room Services Also Can Be Billed

Critical care services and an emergency room visit on the same day also can be billed. The Medicare Carriers Manual appears to reject such a combination when it states that If critical care is required upon the patients presentation to the emergency department, only critical care codes 99291-99292 may be reported. Emergency department codes will not be paid for the same day.

The carriers manual is referring, however, to a situation where the patient arrives at the emergency room in critical condition, according to Leineke. If a gastroenterologist did a complete evaluation of a patient who arrived at the emergency room (ER) in stable condition but later became critically ill, then it is appropriate for the gastroenterologist to bill both the critical care services and the emergency room visit.

The change in the patients condition requires a separate service to be performed. What is key is whether or not there was a change in the patients status from stable to critically ill, says Leineke. If the patient arrives at the ER in critical condition, the only services that will be offered will be critical care. However, if the patient arrives in stable condition and then turns critically ill, the gastroenterologist will first perform the usual medical history-taking and examination that occur during a site of service visit.

The previously cited CPT Assistant article also supports Leinekes opinion. The modifier -25 may be appended to the Hospital Inpatient Service code or the Emergency Department Service code to indicate that a significant, separately identifiable E/M service was performed by the same physician on the same day critical care services were provided.

Service Must Qualify as Critical Care

Leineke stresses that gastroenterologists must make sure the requirements for critical care have been met before billing the service. One of the most important is the need to provide full attention to the patient. To be considered critical care, the gastroenterologist needs to give the patient his or her full attention, she explains. If the gastroenterologist is dealing with other patients at the same time, its not critical care.

Also, the total duration of the critical care provided must be longer than 30 minutes. Code 99291 is used to report the first 30-74 minutes of critical care, while code 99292 is used to report each additional 30 minutes beyond the first 74 minutes. For critical care of less than 30 minutes total duration on a given date, CPT advises that it should be reported with the appropriate E/M code.

Finally, theres some confusion concerning where the service can be performed. Critical care can be performed in many different settings, Leineke notes. Whats important is that the patient must meet the definition of critically ill. Just because a patient is in the intensive care unit, doesnt necessarily mean he or she is unstable or critically ill.

Documentation Needed for Both Services

To prove that requirements for critical care were met and that two separate E/M services were provided, gastroenterologists should pay attention to their documentation in the patients medical record, which may have to be included with the claim to receive reimbursement. Advise physicians to submit documentation when critical care is billed on the same day as other evaluation and management services, the Medicare Carriers Manual notes.

The documentation for the site of service E/M visit will contain notes from the gastroenterologist regarding the history and exam of the patient. The critical care documentation needs to be more detailed, however, to prove that critical care services were warranted and provided. In addition to noting the patients medical condition, the documentation must indicate the time the gastroenterologist spent with the patient, Leineke says.

The gastroenterologist must document what he or she means by critically ill and the amount of time spent providing critical care services, she explains. The medical record also must support the fact that the gastroenterologist focused his or her full attention on the patient.