ER and Critical Care


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ok i have heard different ways to bill ER and critical care, medicare will only pay 99291 and deny 99285 as bundled, i heard to put -25 on 99291 and it will get paid.. well a patient came in, SOB, cough,etc.. the Er physician billed a 99285 which was correct for the time and evaluation he spent on the patient.. well prior to being discharged the patients condition worsen and had to be intubated and performed CPR and the patient then expired,, so the physician put 99291 because he spent additional time (other than the initial ER visit) trying to stablize the patient,, so all together i have 99285, 99291, 92950, 31500,, i know medicare will deny the ER visit ,, would it be correct to put -25 on the critical care, or just not bill the ER ??
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I would bill the 99291 #25 and then the procedues that are not bundled in the code. I would not bill the 99285 at all. Sometimes level 5 patients turn into critical care and critical care always supercedes coding the level 5. Hope this helps...
Actually, if you bill these codes together the modifier 25 should be on 99285 according to the CMS CCI edit since the 99285 is a column 2 CPT.
The original post was submitted over 3 and a half years ago. 99285 and 99291 are not reported together on the same date of service.

FAQ 7. Can a critical care service code be reported with an E/M code for a Medicare patient cared for by the same physician on the same calendar day?

CMS Transmittal 1548 specifically addresses this question with regard to the emergency department. It states that when critical care services are required upon arrival into the emergency department, only critical care codes (99291-99292) may be reported. An emergency department E/M code (99281-99285) may not also be reported.
Although CMS understands that a patient may need critical care services on the same day where the patient may have only required an inpatient or office/outpatient E/M service earlier in the day, Transmittal 1548 clearly states that hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician (which includes any physician of the same specialty in the same group) to the same patient.

In other words, if a Medicare patient presents to the emergency department and receives a Level 5 ED E/M workup, and later in the shift unexpectedly clinically deteriorates requiring critical care services, according to CMS the "same" ED physician can only report either the ED E/M service or the critical care service -- but not both.