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Thread: Critical Care & E/M code for same ER visit

  1. #1

    Default Critical Care & E/M code for same ER visit

    AAPC: Back to School
    Can Critical Care and an E/M be billed for the one ER visit for the same ER physician? I am being advised to bill both but everything I have read states that those two codes cannot be billed for the same visit but can be billed for the same date of service...for instance, if the same ER physician sees a patient in the ER then is admitted to the ICU where he "crashes" and that same ER physician then performs Critical Care services in the ICU. Thanks!

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default What would be the reason to code both?

    First - Critical care IS an E/M code.

    I can't see any reason to want to code both Critical Care and another E/M code (such as emergency service). If the patient is critically ill, and the care provided is critical care, then use ALL the time spent with the patient to determine the level of critical care (99291 and 99292 for as many units as documented).

    You are correct, the only time you would use both critical care and another E/M code is when two distinctly separate visits occurred ... the patient did not require critical care on the first visit, but worsened and later the same day requried critical care.

    Bear in mind that if you attempt to code both your documentation will have to clearly identify the separate encounters. Any time spent in performing any procedures or services separately reported from critical care CANNOT be counted in critical care time.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3

    Default Critical Care & E/M code for same ER Visit

    Thank you for your reply. I think the reason I am being advised to code both for the same visit is, let's say, a patient comes in with a headache and during the treatment goes into cardiac arrest, I am being advised to code a regular E/M visit for the headache and Critical Care for the cardiac arrest. Would it be permitted under those circumstances?

  4. #4

    Default CC and Visit

    CC and a visit can be coded in the scenario you describe. The patient comes in has an E&M and later crashes during the same visit requiring CC. This should be very rare. More typically the patient presents Critically Ill.
    You can code it but getting paid is another issue. I would recommend sending a copy of documentation that supports both with the initial claim to avoid a
    You will also need modifier(s). Probably 25. But if one is included in the other on CCI Edits...not sure if that is the case, but you would need a 59....


  5. #5

    Default CC and Visit

    I found the following information at this CMS website:

    Q7. A patient presents to the emergency room. The physician provides ED services and admits the patient. The patient is getting ready to be transferred to the floor when they crash. The physician has provided ED, initial hospital, and critical care services on this same day. What can the physician bill?
    A7. When critical care and ED services are provided on the same date, only critical care services may be billed. In the example, the physician provided initial hospital services and then provided critical care services. If the documentation shows the break in services and the change in the patient's condition, both the initial hospital visit and the critical care services may be billed. If there is no break in services, bill the critical care services. Please let us know that you have additional documentation available using the narrative portion of the electronic claim. For more information, see CMS IOM Publication 100-04, Chapter 12, Section 30.6.12.H.


  6. #6

    Default CPT vs. CMS

    You're right. That is the Medicare interpertation. So I stand corrected. But it isn't the CPT definition. So it becomes a matter of coding philosophy for non government cases. This is AVCEP's approach. But they also document the Medicare transmittal.

    FAQ 6 Can a critical care service code be reported with an E/M code for a patient cared for by the same physician on the same calendar day?
    A. Yes, CPT allows for reporting both an E/M service and a critical care service on the same day. Additionally, CPT does not distinguish as to site of service or which service comes first.

    Some payors may require the -25 modifier be attached to the non-critical care EM service (see below).

  7. #7

    Default CPT vs CMS

    Your reply states that the same physician can bill for both on the "same day" which CMS also states. However, I don't see where your reply addresses the "same visit" scenario.

  8. #8

    Default CMS vs CPT

    I agree that CMS differentiates between the two. But I don't see where CPT differentiates between the two. It is rare; but I have seen cases where the patent has an evaluation and management service and crashes during the same visit. Those could be, although it's rare, two distinct services.

    Can an ER physician bill for an E/M service and Critical Care on the same calendar date?
    Not for Medicare patients. CMS specifically prohibits this, for the ER E/M codes only. CPT guidelines will permit this, so long as the services provided are separately
    I see no differntiation from any source between same day and same visit on any non Medicare source. I realize the question is about calendar date which Medicare won't pay for. But with CPT there is no differentiation between date and vist.

    Think we will agree to disagree. But thank you for the input.

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