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 [...]