Consider the following… A patient arrives in cardiac arrest; the emergency physician gets a brief history from the medics and does a quick exam. CPR is performed from arrival until the patient is pronounced 20 minutes later, and the course is well documented. Would you bill evaluation and management in addition to the 92950 for CPR? If so, what level?

 

What presents as a simple question also raises several controversial issues in coding for E&M. In particular, we need to define what is “significant and separately identifiable” beyond the performance of CPR and on how to define the E/M component "additional workup, planned, ordered or performed." Here is my short answer.

First, let’s deal with the procedure, 92950 Cardiopulmonary resuscitation. It is not a time-based code so it is not exclusive of all services performed during the CPR event. But, is there any E/M work during CPR that can be billed separately?

While CPR is not a “surgical” service, it is subject to “global surgery policy” that bundles the normal pre-, intra- and post-procedure components related to the procedure. The E/M content related to determining the need for the procedure is specifically not bundled. It is likely that while CPR was being conducted, the emergency physician gathered some history from paramedics or family along with exam data. For example, minimally the patient’s appearance might be noted, whether there was frothing sputum or cyanosis. I would judge these to be findings outside the scope of the CPR procedure that would yield some amount of E/M content.

If we can bill a separate E/M, we might still wonder if we should or if we should bill the highest level possible. If it’s a "no code," or a “show code”, where CPR is being performed by protocol but resuscitation is highly unlikely and you are simply delaying the moment at which you pronounce the patient deceased, deciding which E/M to bill is more of a customer service decision than a coding decision.

The case presented sounds like a "show code," with only the minimal period of CPR called for by EMS protocols. A good PR move might be to bill anything from a 99281 to a 99284; the E/M content would not usually be the deciding factor in what to bill. But, a good argument can be made for billing the highest level documented as the physician is not covered by Good Samaritan laws in the ED and can be sued for simply being on duty when an effectively deceased patient shows up in the ED.

So, could a 99285 level be justified? It could when a “show code” or “go code” are clear in the chart.

In a “go code” you are going to give it everything, use every med, every procedure and every trick you know, going well beyond the minimum 20 minutes of resuscitation efforts. You are ordering labs, EKG, monitor and probably more than one round of ACLS meds. In these cases, the Risk of the Presenting Problem is High and Data will normally be Extensive, predicting a 99285 level of service.

I view the Diagnosis and Management Options as Extensive in this case because it is beyond what is available in a physician’s office, qualifying it as "additional workup performed" even though the patient is never admitted or a consult is not obtained. But, even if you don’t score it as Extensive because it is done in the ED, the Risk and Data allow for High MDM.

In most ED charts it will be sufficiently apparent, even if not stated in the documentation, that the history was limited due to treatment urgency. The exam is subject to the Acuity Caveat, which limits content within the constraints of the same urgency. Running CPR is certainly a reason to limit the exam. So, with the history and exam caveats, and high MDM, a 99285 can be reported along with the 92950 CPR, if your policy allows for that high level when a CPR event does not produce the desired result.