Internal Medicine Coding Alert

Question: A patient is admitted for chest pain and later takes a turn for the worse and is moved to the intensive care unit (ICU). The doctor is called back to monitor and treat the patient. Can I bill for an admission and critical care services on the same day by the same doctor? If I use 99223 and 99291, do I need a modifier?

Washington Subscriber

Answer: Yes, you can use the code for initial hospital admission, 99223, and then code the critical services later in the day with 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 ( each additional 30 minutes [list separately in addition to code for primary service]) if the encounters meet the criteria for those codes.

The Medicare Carriers Manual says in Section 15508(F) that "if there is a hospital or office/outpatient evaluation and management service furnished early in the day and at that 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."

To use these codes, you need to be sure that the doctor provided critical care services for at least 30 minutes during the second encounter with the patient and that he or she documented in the medical record the amount of time spent providing critical care.

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), and be sure to provide documentation supporting your use of two E/M codes on the same day.