ED Coding and Reimbursement Alert

Experts differ on +99292 coding, so be sure to check with payer.

ED coders should strive to use high-paying critical care codes whenever appropriate; however, coders must adhere to strict rules regarding 99291 and +99292. Learn how to carve out separately identifiable services, and identify possible +99292 scenarios, with this expert advice on filing critical care claims. Parse Out Separate Services Before Starting CC Count

The $kinny: The payout for critical care is high. A unit of 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes ...) pays about $221 per encounter (5.99 transitioned facility relative value units [RVUs] multiplied by the 2010 Medicare conversion rate of 36.8729).

Coders should remember, however, that the physician often provides critical care and other (separately codeable) services during the same session. When this occurs, you have to subtract the minutes spent on the services from your critical care tally.

"When a patient requires critical care service, there is a high likelihood that a separately billable service will also be provided," explains Greer Contreras, CPC, senior director of coding for Marina Medical Billing Service Inc. in California.

While 99291 claims will not always contain separately codeable services, critical care does occur in concert with other services, confirms Michael Lemanski, MD, ED billing director at Baystate Medical Center in Springfield, Mass.

Some of the more common services the physician provides in addition to critical care include:

• Intubation (31500, Intubation, endotrachael, emergency procedure)
• Central line placement (36556 [Insertion of non-tunneled centrally inserted central venous catheter; greater than 5 years of age] Lumbar punctures (62272, Spinal puncture, therapeutic, for drainage of cerebrospinal fluid [by needle or catheter])
• Chest tube insertion (32551, Tube thoracostomy, includes water seal [e.g., for abscess, hemothorax, empyema], when performed [separate procedure]).
• EKG interpretations (93010, Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only)
• Focused assessment by sonography for trauma (FAST) exams (93308 [Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study] and 76705 [Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up)]).

Apply the Right Modifier(s) to 99291/Procedure Combos

When the physician provides critical care and a separately reportable service during the same session, you'll 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 the critical care code(s). "If multiple procedures are reported, some payers may require that modifier 51 be appended to the lesser-valued procedure," Lemanski explains.

Consider this detailed scenario from Contreras:

On the claim, you should report the following:

• 99291 for the critical care
• modifier 25 appended to 99291 to show that the critical care and intubation were separate services
• 31500 for the intubation
• 518.81 (Other diseases of lung; acute respiratory failure) appended to 99291 and 31500 to represent the patient's respiratory failure
• 995.1 (Certain adverse effects not elsewhere classified; other anaphylactic shock; angioneurotic edema) appended
• to 99291 and 31500 to represent the patient's edema.

Check Longer CC Encounters for Add-On Opportunities

If you've got an opportunity to report +99292 (... each additional 30 minutes [List separately in addition to code for primary service]) as well as 99291, that adds another $110 to your claim (2.99 transitioned facility RVUs multiplied by 36.8729.).

Remember: You'll still have to remember to carve out separately reportable services before counting your critical care minutes on 99291/+99292 claims.

Consider this detailed scenario from Lemanski:

• A 67-year-old woman arrives via emergency medical service (EMS) with mild sub-sternal chest pain and severe shortness of breath. She is in obvious respiratory distress, diaphoretic, and hypoxic with oxygen statistics in the low 80s. An examination reveals acute pulmonary edema.
• The ED physician first treats the patient with continuous positive airway pressure (CPAP), intravenous (IV) nitroglycerin and IV furosemide. Within 20 minutes, the patient becomes apneic and requires intubation for respiratory support. The ED physician inserts a central line for administration of vasopressors. Documentation indicates 90 minutes of critical care time, exclusive of any separately billable procedures.

On this claim, report the following:

• 99291 for first 74 minutes of critical care
• 99292 for the remaining 16 minutes of critical care
• Modifier 25 appended to 99291 and +99292 (if your payer requests it) to indicate the critical care and line insertion were separate services
• 36556 (... age 5 years or older) for the line insertion31500 for the intubation.