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Billing Critical Care ER and ED E&M Same Day

  1. #1
    Default Billing Critical Care ER and ED E&M Same Day
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    Scenario: Patient is seen in ER and physician wants to admit, but patient refuses and leaves- coded as a 99285. Later in day, patient returns to ER and is ultimately admitted and this visit is coded as a 99291. For proper billing, does a 25 mod need be applied? And if so, which code gets the mod - Critical Care 99291 or ED code 99285?

  2. #2
    Per CMS: 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.

    Per ACEP:
    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.
    Last edited by Mojo; 05-11-2011 at 09:44 PM. Reason: Unable to access for reference on 5/10/11.

  3. #3
    I am not an expert. But still I will try this.

    1) Do not need mod 25 for any visit

    2) I assume if the patient came and left and came back at night time by the time they admit it will be the next day ( after 12 pm).

    In that case I think the ED visit (1st visit) can bill seperately.


    everything comes under one day you may bill with modifier 27 for second visit provided with supporting documentation for both visits.

    I will wait for response from others

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