Health Information Management

Do not report emergency E/M codes with critical care codes during same encounter

APCs Insider, February 29, 2008

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QUESTION: When is it appropriate to report emergency evaluation and management (E/M) codes (99281-99285) and critical care codes (99291-99292) on the same claim?

ANSWER: Unlike on the professional side, CMS guidelines state that outpatient hospitals cannot report emergency E/M codes (99281-99285) with critical care codes (99291-99292) during the same encounter. When hospitals provide at least 30 elapsed minutes of active face-to face documented critical care (i.e. time that can be composed of physician and/or staff efforts) the hospital should report code 99291. If the physician and/or staff perform critical care for less than 30 elapsed documented minutes, report this encounter using emergency E/M codes consistent with your own hospital internal guidelines.

Note that when the emergency department E/M service is provided during a separate and distinct encounter from the critical care service, you can bill the emergency department E/M code on the same claim as the critical care code, but you must append modifier -27. Also, report condition code G0 if the services were provided in the same revenue center. For more information on separate and distinct visits, the proper use of modifier -27, and condition code G0, see Appendix B of the I/OCE, Medicare Claims Processing Manual, Chapter 4, Section 180.4, and Program Memorandum A-01-80.

Note that under OPPS, status indictors identify how individual CPT codes are reimbursed through the APC methodology. Status indicators do not determine whether you can bill CPT codes together. Check the National Correct Coding Initiative edits and CPT guidelines. For Medicare claims, use CMS guidelines to determine whether you can bill CPT codes together.



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