Code Carefully When Providing Other Services On the Same Date as Critical Care
Published on Fri Sep 01, 2000
Many subscribers are unclear about the specifics of hospital coding for pulmonary care, specifically when critical care is involved. Careful attention to the insurers guidelines and Correct Coding Initiative (CCI) edits can help resolve many of these issues.
Coding Two Hospital Visits on the Same Day
A pulmonologist visits a patient with emphysema (ICD-9 492.8 ) who is in stable condition. The doctor examines the patients lung volume report, performs an expanded problem-focused exam and directs the respiratory therapist to adjust the ventilator settings. The pulmonologists visit meets the criteria of 99232 (subsequent hospital care, per day, for the evaluation and management of a patient), which he documents in the patients chart.
Later that day, the patient has a respiratory arrest (ICD-9 799.1 ), and the pulmonologist returns to the hospital to provide one hour of critical care services (99291, critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes). Can the pulmonologist bill for the visit in the morning and the critical care in the afternoon?
Most of the time, we wouldnt bill two evaluation and management (E/M) codes on the same day for the same patient, says Shirley Pope, office manager at Asheville Pulmonary Associates in Asheville, N.C., but this is the one exception. If the pulmonologist makes rounds in the morning, then the patient crashes in the afternoon and he has to go back to treat the patient as critical care, you can bill for both E/M visits.
Section 15508(F) of the Medicare Carriers Manual states, 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.
Billing for the morning E/M code and the afternoon critical care code requires modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), says Lori Patak, supervisor of the pulmonary department at United Medical Associates, a four-pulmonologist practice in Johnson City, N.Y. Respiratory arrest definitely would meet the criteria for a critical care service, she says. Therefore, report 99232 for the morning hospital care with modifier -25 and include the ICD-9 code for emphysema (492.8).
To avoid the risk of your insurer paying the critical care code but not the previous hospital visit code, you should send your claim via hard copy (rather than electronically). Attach chart notes to prove medical necessity for both visits showing that the patients care deteriorated later in the day.
In addition, your notes must indicate the amount [...]
