Critical Care NCCI Edits For 2007

NCCI has some important updates for 2007, If you need to report an emergency department (ED) visit as well as a critical care code (99291), you should keep in mind that a bundle, care of the National Correct Coding Initiative (NCCI), version 12.3, prevents you from reporting both.

The code range that you should be aware of is 99281-99285 alongside critical care code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes). The ED visit is now a component to the comprehensive critical care service with the new NCCI edit, you can’t separate this with a modifier. There are currently no known exceptions to this because of a modifier indicator of “0.”

A good example would e if a pregnant patient presents to an ED after a fall, where she is seen by the ob-gyn on call. The ob-gyn determines that the patient has no apparent effects of the fall because the fetal heart rate is strong, and he finds no evidence of bleeding. The ob-gyn discharges her home, but four hours later she presents to the ED with hemorrhaging and falling blood pressure. The same on-call ob-gyn admits her to critical care for 35 minutes in total.

In this case, you should report 99291 only but remember, that you may only use this code once per day. CPT 2007 has added instructional text to help you decide when you should report a consultation service, and now makes clear that you should not claim a consult if the surgeon assumes responsibility for management of even a portion of the patient’s condition(s). The new descriptors for 99251-99255 eliminate the word “initial” and now specify simply, “Inpatient consultation for a new or established patient”.

CPT 2007 has also added text preceding the inpatient consult codes that explicitly reinforces this advice: “Only one consultation should be report by a consultant per admission. Subsequent services during the same admission are reported using Subsequent Hospital Care codes 99231-99233 or Subsequent Nursing Facility Care codes 99307-99310,” depending on the setting. And don’t forget, You must append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the consult code in this case because the surgeon provided a same-day procedure.

View all Articles by: Melissa Clark, CCS-P