Part B Insider (Multispecialty) Coding Alert

Published on Fri Aug 24, 2007 PDF

Make sure your documentation explains why the services were separate

Myth: You can't bill for critical care and an evaluation and management (E/M) visit on the same date.

Reality: You can bill for both, as long as you document that they were separate.

Warning: -Many providers do miss out on reimbursement because they don't know they can bill both services,- says Donna Singh, a coder with Capital Cardiology in Albany, NY. -Even those providers who are aware don't always document properly, so they don't receive the full payment they deserve,- she adds.

Opportunity: -With some changes in documentation habits physicians can commonly report E/Ms with critical care on better than 50 percent or more of their existing cases,- says Jim Blakeman, senior vice president of EGO in Alameda, CA.

The Dec. 2006 CPT Assistant clarified that you can report critical care and an E/M on the same day--or even in the same session in some cases, experts note. 

-Our cardiothoracic physicians will see a patient early in the day, and then get called back for CC [critical care] time because the patient crashed,- says Cheryl Klarkowski, coding specialist with BayCare Health Systems.

Singh has never had any trouble receiving payment for both services on the same date. The carrier will always request documentation, but as long as that's in order, the claims come back paid, she adds.

Some doctors wrongly believe that they can only bill for critical care in the Emergency Department (ED), Critical Care Unit (CCU) or Intensive Care Unit (ICU), says Singh. Other doctors believe that any care they provide in the CCU is automatically critical care, she adds. In fact, you can bill both critical care and an E/M in any setting--including the office.

Sequence: Medicare will only pay for both services if the E/M happens first and then the patient requires critical care later in the day, notes Denae Merrill, a coder for Covenant MSO in Saginaw, MI, and president-elect of the MBS chapter of the American Association of Professional Coders.

But in fact, CPT says you should be able to code both on the same day, regardless of the order they happen in, Merrill adds.

Modifier: You probably don't need a modifier if you-re billing both critical care and an E/M, says Singh. But if the physician performs another service that may include an E/M, make sure you append  modifier 25 to both the critical care and the E/M.

Most payors will prefer the 25 modifier in this situation, notes Suzan Hvizdash, physician educator with the UPMC Dept. of Surgery in Pittsburgh, PA, and a former AAPC National Advisory Board member.

Documentation is crucial: -The key here is for the provider to make very certain it is clear from the documentation that there were two separate services provided,- says Robert LaFleur, a physician and president of Medical Management Specialists in Grand Rapids, MI.

Physicians billing for both -must show that the two separate services can stand alone,- Hvizdash notes. -They don't need to have a different diagnosis, but it should be clear in the documentation as to why the two services took place,- she explains.

-I encourage my providers to include a line in their critical care documentation to the effect that the patient was seen earlier, but their condition has deteriorated,- says Singh. -This way they are actually spelling out that they are performing critical care after another E/M, and why.-

Common mistakes: Singh often sees documentation where the doctor only includes one note for both critical care and the E/M, which won't support billing both. -For example, I-ve seen progress notes where the doctor just adds an addendum for the critical care,- she notes.

If you can't convince your doctor to include two separate notes for the critical care and E/M visits, the doctor should at least separate them within one note, says Merrill. The doctor should document the E/M and why it was an E/M, and then the critical care and why it was a critical care service, she explains.

Some providers also fail to list the stop and start times for critical care, which makes it impossible to bill, Singh says.

Check with your payor: Ask your local Medicare carrier and private insurers how you should report critical care on the same date as an E/M, recommends Jaime Darling, a coder with the EA Health Corp. in Rancho Santa Fe, CA.