tci Medicare Compliance & Reimbursement - 2015 Issue 15

Reader Question: Is it Critical for the ED Physician To Document a Full History for Code 99291?

Question: Does the emergency department (ED) physician need to complete all the HPI, ROS, history, and exam elements in order to bill for critical care time? Answer: No, he doesn’t. You can bill critical care codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (…each additional 30 minutes…) without the elements that are required for the emergency department evaluation and management (E/M) 99281-99285 codes. Unlike the emergency department evaluation and management codes (99281-99285), with which the documentation needs to satisfy either CPT® or Medicare requirements...

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