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Review specific critical care clinical presentations
Outline which scenarios may NOT be appropriate for CC time
Identify documentation and coding requirements
Explore difference between 99285 and CC
Ask yourself two questions:
Was the patient admitted (based on medical necessity) to ICU or taken immediately to the OR? • If yes: strongly consider CC • If no: is it really CC? • If no (and you think it is CC): write a Medical Necessity note
Will the patient die or deteriorate (quickly) if I don’t do something (quickly)? • If yes: document CC • If no: is it really CC? • If no (and you think it is CC): write a Medical Necessity note
CPT: CC is the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. • A critical illness or injury acutely impairs one or more
vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.
CMS: CC involves high complexity decision
making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.
Must be audit defensible
Outside of Medicare/Medicaid, CPT rules may be slightly less stringent
Definitions may “sound the same,” but might be very different!
Medicare rule will almost always trump CPT
Considerable overlap and indistinct border between 99285 and 99291 CPT descriptors
99285 examples tend to suggest a high risk presentation • MVA and symptoms compatible with intra-
abdominal and extremity injuries
99291 examples consistent with high risk presentation PLUS actual positive finding • Auto vs ped with liver lac, pulmonary contusion
Requires 3 key components • Within the constraints imposed by the urgency of the
patient's clinical condition and/or mental status A comprehensive history A comprehensive examination Medical decision making of high complexity
*High Risk* • High severity presenting problem(s) • Poses an immediate, significant threat to life or
physiologic function.
Complicated overdose requiring aggressive management to prevent side effects from the ingested materials
New onset of rapid heart rate requiring IV drugs
Active, upper gastrointestinal bleeding
Patient who arrives immobilized after an MVA with symptoms compatible with intra-abdominal injuries or multiple extremity injuries
Acute onset of chest pain compatible with classic symptoms of cardiac ischemia and/or pulmonary embolus
Sudden onset of "the worst headache of life," and complains of a stiff neck, nausea, and inability to concentrate
New onset of a cerebral vascular accident
Acute febrile illness in an adult, associated with shortness of breath and an altered level of alertness
65-year-old male with septic shock following relief of ureteral obstruction caused by a stone
5-year-old with acute respiratory failure from asthma
45-year-old who sustained a liver laceration, cerebral hematoma, flailed chest, and pulmonary contusion after being struck by an automobile
65-year-old female who, following a hysterectomy, suffered a cardiac arrest associated with a pulmonary embolus
6-month-old with hypovolemic shock secondary to diarrhea and dehydration
3-year-old with respiratory failure secondary to pneumocystis carinii pneumonia
At the bedside or in the ED and immediately available to patient
Requires MD’s full attention, you cannot provide services to any other patient during that period of time
May be aggregated, doesn’t need to be continuous
At the bedside or in the ED and immediately available to patient
Requires MD’s full attention, you cannot provide services to any other patient during that period of time
May be aggregated, doesn’t need to be continuous
Time spent in the box reviewing test results or imaging studies counts
Discussing the critically ill patient's care with other medical staff counts
CPT says yes to documentation, CMS says no
What about CMS and CPT description of “immediately available” when patient is in the cath lab or the OR and you’re in the ED?
Does documenting the record, speaking with family, or other “non-bedside” activity count when the patient is not in the ED?
The 25 minute door to cath lab patient: maybe
Pre-hospital cath activation: probably not (controversial)
CMS: Concurrent critical care services provided by each physician must be medically necessary and not provided during the same instance of time
CPT: Only one physician/provider may report services for a given hour of critical care, even if more than one physician/provider has rendered critical care to the patient
Time spent speaking with family members or surrogate decision-makers counts if
• The patient is unable or incompetent to participate in giving history and/or making medically necessary treatment decisions
• There is a necessity to have the discussion
• There is a summary in the medical record that supports this medical necessity
Time spent speaking with family members or surrogate decision-makers counts if
• The patient is unable or incompetent to participate in giving history and/or making medically necessary treatment decisions
• There is a necessity to have the discussion
• There is a summary in the medical record that supports this medical necessity
Time that does not count • Teaching time at the bedside • Resident time alone at the bedside
Otherwise, the medical review criteria are the same for the teaching physician as for all physicians
Documentation must support all CC criteria
Time that does not count • Teaching time at the bedside • Resident time alone at the bedside
Otherwise, the medical review criteria are the same for the teaching physician as for all physicians
Documentation must support all CC criteria
Accurate time statement always required (avoid about or approximately)
Document 99285 elements or acuity caveat • These visits potentially can be down-coded to 99284-5 • ED course should support high complexity MDM and
establish medical necessity
Document serial assessments and your decision making that involves the organ system at risk
Document the critical lab, imaging, other study and/or EKG findings and their significance
Include diagnostic and therapeutic interventions performed and/or considered • with the “why,” especially if you’re performing
the intervention
Goal is to impart on paper the likelihood of life-threatening deterioration • if you didn’t do something on arrival or if you
didn’t intervene on a study result
Count towards CC time • Interpretation of cardiac output measures • Chest x-ray interpretation • Blood draws, blood gases, and lab data • ECGs • Gastric intubation • Pulse oximetry • Temporary transcutaneous pacing • Ventilator management • Vascular access procedures (outside of central lines)
Separately billed • Wound repair • Intubation • Chest tubes • Central lines • CPR (which is bundled, in and of itself…)
Patient presents with chest pain and has a 99285 service provided • While waiting for a bed, he has an episode of
hypotension and run of ventricular tachycardia
CPT: May report 9928x plus 99291 by same physician on same calendar day
CMS: if critical care services are required upon arrival into the emergency department, only critical care codes may be reported
Patient presents with chest pain and has a 99285 service provided • While waiting for a bed, he has an episode of
hypotension and run of ventricular tachycardia
CPT: May report 9928x plus 99291 by same physician on same calendar day
CMS: if critical care services are required upon arrival into the emergency department, only critical care codes may be reported
Disposition suggesting CC should be considered: • ICU admit (maybe telemetry) • Direct to OR • Death in the ED
Disposition suggesting this is likely not CC: • Floor admit • Discharged home
Documentation suggesting may not be CC • “NAD,” Normal VS, “Resting comfortably” – look at the
nursing notes!
Minimally documented and/or benign ED course that does not support medical necessity
Psych (generally)
High risk presentation with subsequent r/o of critical illness/injury
Urgent call and arrival of specialist is not CC unless necessary time portion of workup was initiated and treated by you
Abnormal lab values alone do not support CC
• unless MDM reflects high complexity MDM • initiation of life-saving assessment/treatment or prevention of a quick
deterioration
This is when your Medical Necessity statement is actually necessary, but our billers like to see it on all CC charts.
Minimally documented and/or benign ED course that does not support medical necessity
Psych (generally)
High risk presentation with subsequent r/o of critical illness/injury
Urgent call and arrival of specialist is not CC unless necessary time portion of workup was initiated and treated by you
Abnormal lab values alone do not support CC
• unless MDM reflects high complexity MDM • initiation of life-saving assessment/treatment or prevention of a quick
deterioration
This is when your Medical Necessity statement is actually necessary, but our billers like to see it on all CC charts.
Consider CC • EKG compatible with ischemia with enzyme changes • Arrhythmias requiring treatment • Hypotension • Pain requiring ongoing IV NTG • Use of IV heparin, lytics • Immediate dispo to cath lab or ICU
Probably not CC • EKG normal and given ASA per protocol • Repeat EKG, enzymes normal • SL or topical NTG only (not given parenterally = less risk) • Dispo home
Consider CC • If symptomatic (eg syncope, altered mental status/
neuro signs, chest pain, dyspnea; not simply palpitations)
• With significant co-morbidities such as ingestion • Treated with electricity, IV drips or multiple doses of
drugs
Probably not CC • PAT converted in field • Spontaneous conversion in stable patient • Asymptomatic AF with single bolus of meds
Consider CC • Hypertensive emergency end organ(s) affected
(brain, heart, lungs, kidney) • Treatment ongoing, with ICU admit
Probably not CC • Hypertensive urgency • Incidental finding unrelated to main problem • May get PO or IV Rx, but floor admit or
discharged
Consider CC • Syncope plus a significant co-morbidity • Arrhythmias (see prior slide!) • Lower or UGI bleed • Significant hypovolemia • Altered mental status or seizure • Pulmonary embolism • ICU admit
Probably not CC • “Weak and dizzy” • No significant co-morbidity • Simple faint
Consider CC • Status epilepticus • Complex febrile • Context of trauma, OD or ingestions • ETOH or drug withdrawal
Probably not CC • Recurrent • Noncompliant • Sub-therapeutic meds
Consider CC • Abnormal vital signs requiring treatment • Any airway issues • Start/consider TPA • Rapid assessment and transfer for definitive
treatment at a stroke center
Probably not CC • Stable patient with completed stroke
Consider CC • CPAP • High flow oxygen, continuous nebs and ICU admit • Altered mental status • Impending respiratory failure documented • Intubation performed or considered • CHF with significant worsening of pulmonary edema
or severe dyspnea
Probably not CC • 2-4 nebs or continuous nebs plus steroids and pt
improves rapidly/clears • Dispo to floor or home
Consider CC • Immediate dispo to OR (AAA, perforated viscus) • Hemodynamic instability • ICU admit (bowel ischemia, sepsis)
Probably not CC • Appy/diverticulitis: routine and admitted to floor • Perforated appy or diverticulitis initially
admitted to floor
Consider CC • Hemodynamic instability/abnormal VS • Possible cord injuries • Unresponsive/altered • Procedures such as chest tube, intubation • Dispo to OR or transfer to Trauma Center
Probably not CC • Low mechanism in alert patient w/o complaints • Isolated extremity injuries w/o neurovascular
compromise
Consider CC • High lethality agent requiring intervention or
close monitoring • Seizures, coma, arrhythmias, hypotension
Probably not CC • Benign overdose with watchful waiting
Consider CC • Stridor, wheezing. hypotension • IV epi or pressors
Probably not CC • IM epi and/or IV steroids and clears
Consider CC • Most admitted DKA and/or other metabolic
acidosis admitted to ICU • Hyperosmolar states (eg coma)
Probably not CC • Mild DKA treated in ED and sent home
Consider CC • Abnormal EKG • Symptomatic (eg confusion, muscle weakness) • Requires IV treatment with active monitoring
(severe hypokalemia) • Emergent dialysis required • Acute renal failure with ongoing management
(ongoing fluids, bicarb drip)
Consider CC • Sepsis bundle management (central line,
elevated lactate) • ICU admit • Immunocompromised patient • Transplants/cancer patients
Consider CC • Hypothermia: either PLUS another problem or
more intervention than passive external re-warming
• Lightning strike • CO with signs/symptoms and HBO treatment or
emergent transfer
Consider CC • Delirium or organic cause identified plus ICU
admit
Probably not CC • Agitation due purely to psych issue
Always document to support Level 5 billing
Accurately document time Write a medical necessity statement if
you think it’s CC