Forum - Questions & Answers

May 26th, 2009 - trichards75

CPT code 99291 and 99238

Can these two codes be billed on the same date and is a modifier necessary?

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May 26th, 2009 - Codapedia Editor 1,399 

CPT code 99291 and 99238

Here's what the Medicare Claims Processing Manual says:

H. Critical Care Services and Other Evaluation and Management Services Provided on Same Day
When critical care services are required upon the patient's presentation to the hospital emergency department, only critical care codes 99291 - 99292 may be reported. An emergency department visit code may not also be reported.
When critical care services are provided on a date where an inpatient hospital or office/outpatient evaluation and management service was furnished earlier on the same date at which time the patient did not require critical care, both the critical care and the previous evaluation and management service may be paid. 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.
Physicians are advised to submit documentation to support a claim when critical care is additionally reported on the same calendar date as when other evaluation and management services are provided to a patient by the same physician or physicians of the same specialty in a group practice.

I have seen these two services reported together, but never paid. When I have reviewed the documentation, I haven't seen the separate, distinct work. If the patient was being discharged that day, they usually didn't meet the criteria of critical for the first visit.

If the patient dies, you cannot bill the discharge service. If the patient is transferred to another facility, you can't bill for the critical care and a discharge service. (Same episode of care.)

So, although they are not bundled, it is highly unlikely to be paid.

For any E/M with critical care, you need modifier 25 on the E/M and you must send notes.

Can you describe your situation?

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May 27th, 2009 -

CPT code 99291 and 99238

Hi, thank you for your response. Same day critical care and later that day the patient dies.

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Jun 16th, 2009 -

Critital care followed later in the day with death pronouncement D/C e/m

According to CMS transmittal 1460, dated 02-28-2008, see last page, section E of the site below:

CPT says: "Critical care and other E/M services may be provided to the same patient on the same date by the same physician."

Just curious: Why couldn't you bill for performing critical care in the a.m. and then much later the same day the patient dies and you bill for discharge management? This above transmittal states that the Physician who personally performs the pronouncement of death shall bill for the discharge management. If he was the same MD that earlier in the day provided necessary critical care services why can't he be paid, assuming of course his documentation is extremely clear. 99291 and 99238 are not showing up as mutually exclusive codes according to CCI. You do need a modifier 25, though.

Your thoughts, arguments, justifications?

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Jun 16th, 2009 - Codapedia Editor 1,399 

Critical care and death pronouncement

This is an interesting thread.

Whenever I've reviewed notes, I haven't found these services to be separate and distinct. Of course, my own note reviews represent a limited sample. The patient was being cared for, died, and it appeared to be one episode of care, all critical.

I'd be very interested to know if you've been paid for both, and if so, what the documentation looked like.

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May 26th, 2009 - Codapedia Editor 1,399 

CPT code 99291 and 99238

I should add: I think you have a better chance of being paid for E/M services before critical care: when the patient wasn't that sick in the a.m., a subsequent hospital visit is done and documented, and then the patient crashes later in the day.

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