Pulmonology Coding Alert

Question: The pulmonologist saw a patient in the ED and later that day furnished critical care services to him. Can both be billed?

Ohio Subscriber

Answer: Section 15508f of the Medicare Carriers Manual (MCM) prohibits payment for ED visits if reported with critical care codes (99291-99292) for the same date of service. You may report other office/outpatient services (as well as inpatient E/M codes) on the same date as critical care if the other E/M was provided before the critical care. If it was provided after, add your total time for the day and report your services as 99291-99292.

In general, when critical care is the first encounter of the day, any visits later in the day to verify the status of the patient are not separately billable. However, if the patient is stable during rounds, and later you are called to provide critical care services, you can bill for both. 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 and be prepared to submit documentation for both services to demonstrate the time of occurrence for each.

Questions answered by Carol Pohlig, RN, CPC, a reimbursement analyst for the office of clinical documentation in the department of medicine at the University of Pennsylvania in Philadelphia.