ED Coding and Reimbursement Alert

Question:

Mississippi Subscriber

CPT^® specifically states that critical care and other E/M services may be provided to the same patient on the same day by the same physician. In fact, that is a direct quote, but Medicare does not allow both services to be reported in the emergency department setting.

CMS describes the criteria in which they will pay for both a regular E/M and a critical care code in. In Pub 100-4, Chapter 12, Section 30.6.12 (H), the text is as follows:

"When critical care services are required upon the patient's presentation to the hospital emergency department, only critical care codes 99291-99292 may be reported. An emergency department visit code may not also be reported.

When critical care services are provided on a date where an inpatient hospital or office/outpatient evaluation and management service was furnished earlier on the same date at which time the patient did not require critical care, both the critical care and the previous evaluation and management service may be paid. Hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician to the same patient.

Historically, Medicare would allow both services only if the ED E/M occurred first and then was followed by a significant decline in the patient's condition to the extent that became critically ill, but the underlined sentence indicates that policy has changed.