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

Compliance Monitor Q&A , February 29, 2008

Last week, we ran the following question. This week we are running a corrected answer.

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

A: Unlike reporting these services for professional billing, according to CMS guidelines for outpatient hospitals, it is not appropriate to bill 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, time which can be composed of physician and/or staff efforts, the hospital should report 99291. If the physician and/or staff perform critical care for less than 30 elapsed, documented minutes, you should report this encounter using emergency E/M codes consistent with your own hospital internal guidelines.

If the emergency department E/M service is provided in 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, appended with modifier -27. You should also report condition code G0 if the services were provided in the same revenue center. For more information on separate and distinct visits and 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.

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 (NCCI) edits, CPT guidelines, and for Medicare claims, CMS guidelines, to determine whether you can bill CPT codes together.

This answer was provided by the panel of the APCs Weekly Monitor.