General Surgery Coding Alert

Question: My surgeon performed critical care services and laceration repairs on the same day. I keep getting denials for the critical care. How should I code these services?

Arizona Subscriber

Answer: You need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the critical care code (99291-+99292, Critical care, evaluation and management of the critically ill or critically injured patient ...) Critical care codes fall under the E/M section of the CPT manual. Without modifier 25, the payer will consider the E/M service related to the procedure your surgeon performed and will not pay you separately for the critical care.

Remember: Critical care can occur wherever the physician performs critical care on a patient -- the patient does not need to be in the intensive care unit (ICU) or emergency department. Be sure to check the encounter notes before deciding whether to use 99291-+99292 to report critical care services.

What drives critical care is the patient's condition, not the location. However, if the surgeon provided care in an unusual location, such as the office or a clinic, document why there was an unusual place of service for such a highacuity treatment. Conversely, treating a patient in a location where critical care is common, such as the ICU, is not a guarantee that critical care occurred. Be sure the documentation justifies a critical care  ode before reporting 99291-+99292.