ED Coding and Reimbursement Alert

- and remember to report nonbundled services separately When a patient presents with a serious injury or medical condition, ED coders should be on the lookout for critical care services the physician might provide. After all, these codes sport higher relative value units (RVUs) than standard E/M codes. But be careful you don't miscode a claim in your zeal to use the high-RVU critical care codes. You-ll have to prove that the patient needed critical care services before considering 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) or +99292 (... each additional 30 minutes [list separately in addition to code for primary service]), or you-ll likely receive a denial for your claim. Establish Critical Illness or Injury First According to CPT, a patient must be critically ill or injured for critical care services. Translation: "A critical patient is the one you stop whatever else you were doing to go see ASAP. They are so sick that if you don't intervene, they will get worse or die," says Michael Lemanski, MD, ED billing director at Baystate Medical Center in Springfield, Mass. According to Lemanski, examples of possible critical care scenarios include patients: - with acute myocardial infarction, especially those requiring thrombolysis - requiring intubation - with respiratory failure from acute pulmonary edema, chronic obstructive pulmonary disease (COPD), etc. - with hypertension that requires treatment - who are unresponsive due to overdose, stroke, seizure, etc. - with bacterial meningitis or status epilepticus. Consider this example from Michael Granovsky MD, CPC, FACEP, president of MRSI, an ED coding and billing company in Woburn, Mass. A 67-year-old patient with COPD presents to the ED in severe respiratory distress with an acute exacerbation of his underlying lung disease. Despite multiple rounds of nebulizers, steroid treatment and additional supplemental oxygen, the patient develops worsening respiratory distress and ultimately suffers a respiratory arrest and requires intubation. The physician documents that she spends 45 minutes outside of separately billable procedures caring for this critically ill patient. On the claim, you would report the following: - 99291 for the critical care - modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99291 to show that the critical care and intubation were separate services - 31500 (Intubation, endotracheal, emergency procedure) for the emergency intubation - 799.1 (Respiratory arrest) and 491.21 (Chronic obstructive bronchitis; with [acute] exacerbation) linked to 99291 and 31500 to prove medical necessity for the encounter. Observe Critical Care Bundles As shown in the above example, some services are separately reportable from critical care, says Jamie Darling, CPC, coder at EA Health Corporation in Solana [...]