Internal Medicine Coding Alert

Question: An internist admits a patient to the hospital for alcohol abuse, respiratory failure, renal failure and sepsis. After spending 90 minutes providing critical care services to the patient, the internist admits the individual to the hospital. Should I report one or two E/M services?


California Subscriber


Answer: Because the internist, in this case, provides the critical care services before the admission, you should code only the critical care service. If documentation supports that the internist spent 90 minutes providing critical care services, submit 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the first 74 minutes.

To capture the additional 16 minutes of critical care time, also report add-on code +99292 (... each additional 30 minutes ...). All other same-day evaluation and management services, including the hospital admission (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...), are bundled into the critical care services (99291-99292).

Exception: If, however, the admission occurs prior to the critical care, you should charge both services. For example: Suppose the internist had initially admitted the patient for alcohol abuse and difficulty breathing. That afternoon, the patient goes into respiratory failure, and the internist provides critical care services.

Because the internist initially provided noncritical care and then performed critical care, you should report the admission, as well as the critical care. Submit 99291-99292 for the critical care and 99221-99223 appended with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for the initial hospital care.

Also: Be prepared to submit hard copy and documentation to demonstrate that the internist rendered services at different times.

Don't forget: Critical care services include several procedures that you should not report separately. CPT's critical care services introductory notes specify that the following are part of critical care services:

• chest x-ray interpretation (71010-71020)

• cardiac output measurements (93561-93562)

• pulse oximetry (94760-94762)

• blood gases and other information stored in computers (including blood pressures, hematologic data, ECGs [99090])

• gastric intubation (43752 and 91105)

• ventilation management (94656-94662)

• temporary transcutaneous pacing (92953)

• vascular procedures (36000, 36410, 36415, 36540 and 36600).