Oncology & Hematology Coding Alert

Question:  My doctor saw a patient in the office (99215) and then decided to admit her to the ICU. When he saw the patient in the ICU later that same day, he documented and billed 99291. May we bill both services?

New Jersey Subscriber

Answer: If your physician performed all the components required for the office E/M service prior to the critical care (minimum of 30 minutes) service in the ICU, you may be able to bill each service separately. The key is that your doctor must complete two separate services, with the standard E/M service distinct from the critical care services provided. You also want to be sure that the documentation meets all of the requirements for a critical care service. Simply being in the ICU is not sufficient to support reporting a critical care code.

Assuming the encounters meet the requirements, you should report 99215 (Office or other outpatient visit for the evaluation and management of an established patient …) for the office E/M, and report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the first 30-74 minutes of critical care services provided. Depending on the payer, you may 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 99215 to indicate that it was a separate service

Denial prevention: Medicare advises physicians "to submit documentation to support a claim when critical care is additionally reported on the same calendar date as when other evaluation and management services are provided to a patient by the same physician or physicians of the same specialty in a group practice," according to Medicare Claims Processing Manual, Chapter 12, Section 30.6.12.H (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf).

Watch for: If the encounter began as a standard E/M and ended with services that meet the requirements for a critical care code, you should report only the critical care code. However, for services that don’t meet the 30 minute critical care threshold, report the appropriate E/M code.