Billings Clinic Cody

FigureWhat a job we do! Emergency physicians are on the front lines of our nation's health care system, providing immediate life-saving care to critically ill and injured patients, and we often do this without breaking a sweat. That confidence and capability often results in emergency physicians undervaluing the services they provide. But EPs should realize that in many cases in which they provide critical care, they neglect to document it, and that leads to foregoing appropriate reimbursement for the services provided. In the past several years, the definition of critical care has been loosened. In the past, patients had to be “potentially unstable.” Importantly, the current CPT definition for critical care now states that “there is a high probability of imminent deterioration in the patient's condition.” This redefining of critical care allows additional patients to meet the criteria of critical care. Patients now typically qualifying for critical care frequently include: ▪ Chest pain patients requiring nitroglycerin and those with EKG changes, active angina, unstable angina, or acute MI. ▪ Dyspnea patients requiring aggressive interventions such as multiple nebulizer treatments, high-flow oxygen, and close monitoring, with a clinical condition such as severe asthma, pneumonia, or congestive heart failure. ▪ Severe metabolic derangements such as diabetic ketoacidosis, dehydration, or renal failure. Table: Billing for Critical CareContrary to common misconceptions by emergency physicians, these examples show there is not a clinical requirement for pressors, intubation, or invasive monitoring. Experience has shown that experienced emergency clinicians often undervalue the complexity of their work. The new CPT definition for critical care states there must be “a high probability of imminent deterioration in the patient's condition” Critical Care Threshold Time Keep in mind that in addition to meeting the definition of critical illness or injury, the physician also must deliver 30 minutes of critical care outside separately billable procedures. Time counting toward the 30 minutes includes direct bedside care of the patient; interpretation of lab and radiology studies; gathering history from family, EMS, and old records; discussion of the patient's case with other physicians; time spent documenting the record; and time spent performing bundled procedures such as reading chest x-rays, interpreting pulse oximetry, drawing blood, and insertion of peripheral IVs. CPT instructs us to report all procedures not specifically bundled with critical care. Those commonly billed in addition to critical care include intubation (31500), central venous access, chest tube (36556), transvenous pacemaker placement (33210), CPR (92950), chest tube (32020), and EKGs (93010). Remember to subtract the time spent performing separately billed procedures from your critical care time. Critical care time often goes well beyond 30 minutes. For the first hour of critical care, report code 99291. For additional critical care time, use the add-on code +99292. See the table for examples. It is rare to have a critically ill patient treated in the ED who does not receive 30 minutes of physician care. The few exceptions include a patient with a ruptured AAA who spends 20 minutes in the ED and goes immediately to the operating room and a multiple trauma/gunshot wound to the chest who is transported immediately to the operating room. A critical care attestation such as “I provided more than 30 minutes of critical care outside of separate procedures” is generally accepted by most payers. Some Medicare carriers are considering asking for start- and stop-time documentation. Does the patient have to be admitted to the ICU? Consider the following vignette: A 40-year-old is brought in with supraventricular tachycardia. Her heart rate is 190 bpm and blood pressure is 90/60 mmHg. She complains of chest pain and dyspnea, and appears distressed. The physician considers electrical cardioversion, but feels a quick attempt at chemical conversion with adenosine is warranted. After a second dose of 12 mg of adenosine, the patient converts to sinus tachycardia. She is observed on the monitor, and labs are normal. After several repeat assessments and a follow-up EKG, she is ultimately discharged. The physician documents 30 minutes of critical care, including time devoted to direct management, repeat assessments, review of the labs, arranging close PCP follow-up, and documenting the record. Does this discharged patient qualify for critical care? The physician felt the patient met the criteria for “imminent danger of deterioration,” which is a clinical judgment that seems reasonable given the patient's level of distress. Does the patient have to be admitted? Although the majority of critical care patients will be admitted to an ICU, an ICU admission is not required, and discharging the patient does not preclude using critical care. Other clinical presentations that may qualify for critical care but can be safely discharged include certain asthma presentations, seizures, and allergic reactions. While E/M codes 99281-99285 have strict bullet-counting documentation requirements for history of present illness and review of systems, etc., critical care does not. Critical care is the only ED time-based code. The chart should support that the patient's condition was “critical” and that a minimum of 30 minutes of care was delivered. The teaching physician must be present and personally delivering care for all of the reported critical care minutes. As you move along through your next busy shift, keep in mind that you may be treating critically ill patients and providing critical care services. Just because you are highly skilled and the patient is not on death's door does not mean that critical care services should go unrecognized. Although it varies by acuity mix, the average ED provides critical care services to roughly three percent to six percent of patients.