Q&A Billing Hospital EM codes with critical care codes - same day

[Linda Smith]

I need some input on when it is appropriate to bill subsequent hospital visit codes with critical care codes to the same patient on the same day (both EM codes?). CPT guidelines state that it can be done and there are no CCI edits to the contrary; however, Medicare is paying on the critical care EM and not the subsequent hospital EM even with a modifier on the hospital EM.

Thanks,

 

[Alicia Scott]

Linda I hope this is not just a case of Medicare doing this because they can. Looking forward to the feedback we get here.

 

[Tamara Lucus]

Without seeing the Medicare remittance advice it's hard to guess why they are denying the charges. I would say it has something to do with the diagnosis or modifier. Medicare does pay for both, unless it has something to do with your Medicare administrator. If the diagnosis and documentation does support the critical care code, then I would call Medicare to see why they denied it. Or look up the LCD for your area. If you have reviewed the documentation, diagnosis code, and that modifier 25 is on the correct E/M codes I would certainly try to appeal it.

 

[Alicia Scott]

Thanks Tammy. Linda, she asked me to add this as well:
" I didn't say, was if the doctor rounded on the patient and then later in the day the patient became critical then you could bill for both."