Pulmonology Coding Alert

Question: Our pulmonologist performed critical care services on a Medicare patient in the hospital. We reported these services with 99291 and 99292. He also performed a procedure that is not included in the critical care codes. Should I append modifier -25 to both critical care codes? Oregon Subscriber Answer: As a general rule, you do not append modifiers on add-on codes. CPT defines critical care as "the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient." Acritical illness impairs one or more vital organ systems so that there is a high probability of imminent or life-threatening deterioration in the patient's condition.

Code 99291 is used to report the first 30 to 74 minutes of critical care service; 99292 is an add-on code for each additional 30 minutes and is listed separately. CPT explicitly states that add-on services are performed in addition to the primary service or procedure and must never be reported as a stand-alone code. All add-on codes are exempt from the multiple-procedure concept.

When a physician performs another procedure on the same day as he provides critical care services to a patient, you should report these services separately. However, you must make sure that (1) the procedure does not have a global surgery period and (2) the procedure is not bundled in the critical care service. If your scenario meets these two criteria, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). This only applies to the stand-alone code 99291. For example, a pulmonologist performs 90 minutes of critical care on an elderly patient with respiratory failure in the MICU. You should report the following:
99291-25
99292. Some coders express the concern that their local Medicare carrier requires them to place modifier -25 on 99292 also. Although this goes against CPT guidelines, they have the right to do this. For example, Arkansas Medicare Part B LMRP says for you to "list the appropriate code 99291/99292 with modifier -25." If you have a question about your local carrier, ask which they recommend. Most coders, however, find no problem getting reimbursed for these codes with modifier -25 appended to the base code if they have appropriate documentation. Advice for You Be the Coder and Reader Questions was provided by Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.