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Coding Consult


Answers to your questions about...family counseling; critical care and modifier -25; E codes

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Choose article section...Family counseling Critical care and modifier –25 E codes

Family counseling

Q: I recently spent an hour with a family discussing an elderly patient's arthritis care. The discussion included answering the family's questions and thoroughly explaining the patient's treatment. How should I bill for this?

A: If the patient wasn't present during the discussion, you'll have a hard time getting paid at all. Based on the time you spent with the family, you might try reporting prolonged services without face-to-face contact (99358, prolonged evaluation and management service before and/or after direct [face-to-face] patient care . . .). However, Medicare and most private carriers consider payment for 99358 to be included in other E&M services that involve direct patient contact.

Critical care and modifier –25

Q:When billing for critical care visits, should I use different diagnosis codes for 99291 and 99292? If I report critical care and two separate procedures, should I attach modifier –25 to both 99291 and 99292?

A: You can use the same ICD-9-CM code for both 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (. . . each additional 30 minutes . . . ). When you attach add-on code 99292 to 99291, you are reporting the additional time you spent providing critical care. Consequently, you don't have to assign a new code for a new condition.

For example, say you treat a patient with heart failure (428.x) for 45 minutes. If your documentation supports critical care, you could report 99291, using 428.x as your justification. You would use 99292 only if your care for the heart failure lasted at least 104 minutes.

Both CPT and Medicare bundle several procedure codes, such as 92953 (temporary transcutaneous pacing), into the critical care codes. Therefore, you shouldn't attach modifier –25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99291-99292.

But if you're reporting a procedure code that CPT doesn't bundle into critical care (for instance, 93000, electrocardiogram, routine ECG with at least 12 leads; with interpretation and report), you could bill the codes separately without modifiers.

E codes

Q:When should we use E codes? Do they help us get reimbursed?

A: Although E codes (E800-E999) don't generate revenue, you should report them in addition to the appropriate CPT and ICD-9-CM codes. Doing so insures that you provide the most specific information possible regarding the patient's injury.

For example, if a patient falls and fractures a finger, you could report E880.1 (fall on or from sidewalk curb) to indicate where a fall that caused the injury occurred. Use the E code in addition to the code for the finger fracture treatment (26720, closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each) and the code for the primary diagnosis, such as 816.xx (fracture of one or more phalanges of hand).


This information provided by The Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact The Coding Institute, 2272 Airport Road South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592; or visit www.codinginstitute.com.


Coding Consult: Answers to your questions about. . ..

Medical Economics

Aug. 20, 2004;81:13.

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