Wiki critical care 99291 and 99285

[vjefcoats]

Hello!
Can anyone tell me if you can bill in ED for 99291 and 99285?? If so, do I need to add modifier 25 or 27 to either?? This will be billing for the facility (ED) and the physician.
Thanks!
Vicki

 

[jimbo1231]

99285/91

Vicki,


There is a valid argument for a scenario where both can be coded. Patient comes to ED with chest pain, looks like angina, probably a 5 based on documentation. But at some point during their stay in the ED they have an MI or go into cardiac arrest requiring intervention and CC of 30 minutes +.
From a CPT point of view coding both seems justified with a 25 (27 is facility side). But my understanding is Medicare will not pay for both in the scenario described above with both during the same ED visit. Doesn't seem right, but they are the feds. In that case the 99291 would be the better code to go with. Not sure if that is a CMS policy or carrier driven. And on payor basis there might be some that will pay for both but will almost surely request supporting documentation. May as well send with the initial claim and be sure that the ED record supports both codes.

Jim