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jdibble

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If someone could help - A patient was admitted by one of our hospitalists and he billed an Initial Inpatient visit. Later that day, the patient became critical was transferred to ICU and the doctor billed a critical care visit, 99291. The insurance paid the critical care visit but denied the EM as only one service allowed per day. I checked the account and see that there was no modifier applied - does this need a 25 modifier and if so, which code would get the modifier?

Thanks for the help :)

Jodi Dibble, CPC
 
CPT states "Critical care and other E/M services may be provided to the same pt on the same day by the same physician." CCI doesn't show any edits for the initial inpt codes with 99291 so you shouldn't need a modifier. The documentation must have total minutes of critical care time (at least 30 min) in order to bill 99291. You may need to appeal with the note. If your dr's note doesn't specifically record the critical care time with pt, you cannot bill 99291.
 
lauried - Thanks for your response. Yes the note does have the time for critical care - I checked that first in case I did have to appeal. I also saw the
CPT description that they could be billed together and checked the CCI edits, but the insurance still denied. I just was wondering if anyone has submitted the charge with a modifier and gotten paid before I appealed. If the modifier isn't the issue then I will appeal.

Thanks for your help.

Jodi Dibble, CPC
 
For our hospitalists, we put mod-25 on the initial E/M code for the day, and also appeal with documentation supporting two separate services on the same day.
Jen
 
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