Medicare Compliance & Reimbursement

Question: Our physician had to intubate a patient who was unconscious. Which level history can the physician report?

Answer: When a patient is unable to communicate, you may consider the history at a comprehensive level, according to CPT guidelines.

The physician's documentation should include a statement indicating, for example, "history incomplete due to patient's condition" or "unable to obtain history because patient is unconscious." The examination should include consistent findings that would demonstrate the patient's inability to communicate with you or your staff.

Make sure to attach modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M service, such as initial hospital care (99221-99223) to indicate a significant, separate service from the minor E/M included in the intubation (31500, Intubation, endotracheal, emergency procedure).

Initial hospital care coding guidelines require the physician meet all three key components. Comprehensive history qualifies for all three levels.

You also may code subsequent care in addition to the intubation and E/M codes. Code 31500 includes a zero-day global surgery period.