Critical Care Billing and Coding in Emergency Medicine. Darron Ramage MD March 11, 2013
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1 Critical Care Billing and Coding in Emergency Medicine Darron Ramage MD March 11, 2013
2 Objectives Definition Teaching Hospital Nuances Facts Interactive Examples
3 None Disclosures
4 Intelligent Medicine by Design
5 Definition Impairs 1+ organ system High probability of imminent or life threatening deterioration Time driven, require at least 30 minutes of patient care Excluding time spent performing separately billable procedures Time spent directly related to patient s care, at the bedside or elsewhere on the floor Bedside care, reviewing labs, xrays, past medical history, consults, etc and time spent in contact with the family
6 Definition 99291: minutes 99292: each additional 30 minutes Ex) 120 min of critical care time would bill out: 99291, X 2 Includes: NG Tubes Transcutaneous Pacing Peripheral Venous Access Excludes: Intubation CPR Central Line Cardioversion Chest tube Wound repair
7 Definition Exceptions noted withinexample standalone as criticalcare; do not need both data and intervention; still need to meet DG Application & use of external, percutaneous or intracardiac pacemaker Nipride IV C1, C2 or C3 fracture - displaced and/or with neuro deficit Nitroglycerin/Tridil IV CPR Nitroprusside IV Intubation Neosynephrine IV Intracranial hemorrhage Epinepherine IV/SQ Data Intervention Abnormal Labs consistent withorgan system failure Procedures (that are good inferences for critical care) Blood transfusion Admit/Xfer to Sat O2 (pulse ox) < 90% cath lab PCO2 > 60 Central lines Bipap or CPAP PO2 < 60 Chest tube 3 sequential breathing tx Creat >2 CPR Continuous Neb. Tx. Hemoglobin (Hgb) < 9 Defibrillation/emergent cardioversion Glucose (Gluc) > 250 NG Lavage/Gastric Lavage Nitro Paste/Patch Glucose (Gluc) accucheck Hi Pericardiocentesis Nitroglycerin SL x 3 or more Glucose (Gluc) < 40 Peritoneal lavage Ph < 7.25 Thoracostomy NG Act. Charcoal/Act. Carbon Sodium (Na) <135 Thoracotomy Potassium (K) <3.2 Thrombolytics IVResuscitation ( 2000cc/2 litresfluids) Potassium (K) >5.6 (non-hemolyzed) Tracheostomy dilantin <10 with active seizure Warming blanket for hypothermia(bear Hugger) Troponin >0.04 Abnormal VitalSigns consistent with organ system failure Examples of IV medications: (Dripor push) Abx for sepsisor meningitis Levetiracetam Respirations (adult) > 24 (Keppra) Respirations (adult) < 10 Adenocard/Adenosine Levophed/Norepinephrine Respirations (child) > 20 Aggrastat/Tirofiban Lidocaine Respirations (adult/child) sternal retraction, nasal flaring, cheyene Lopressor/Metoprolol stokes or tachypnea Amiodarone Temperature (adult) > 104 Angiomax/Bivalirudin lorazepam/ativan Temperature < 96 Atropine Mannitol/Hexan Heart rate/pulse (adult) > 100 Cardene/Nicardipine HCL Midazolam/Versed Cardizem/Diltiazem NaBicarb Heart rate/pulse (adult) < 60 Corlopam/Fenoldopam Mseylate Narcan/Naloxone Systolic BP (adult) > 180 Crofab Natrecor/Nesiritide Systolic BP (adult) < 90 D50 phenobarbitol/phenobarbitone Diazepam/Valium Pitocin/Oxytocin Diagnoses indicativeof criticalcare Dilantin Potassium (K-rider) Anaphylaxis MI (*incl. STEMI/Non-STEMI) Diprivan/Propofol Procainamide/Pronestyl afib, vfib, vtach, aflutter, SVT withhypotension Dobutamine Retavase/Reteplase Bradycardia (*w/atropine therapy) Organsystem Dopamine Romazicon/Flumazepil failure (or potential) Cardiac Arrest Unstable Angina/ACS Fosphenytoin (Cerebyx) Sandostatin/Ocreotide ***COPD/Asthma Exacerbation Pneumothorax Heparin/Lovenox (SQ)/Fragmin Streptokinase/TNKase Acute vertebral fracture Pulmonary edema Insulin Succinycholine/Anectine Drug overdose Pulmonary embolus Integrilin Terbutaline/Brethine Diabetic shock (DKA) Respiratory failure Isuprel/Isoprenaline Theophylline/Dimethylxanthine Hypo/hyperthemia Shock Hypoxia Sepsis (urosepsis/bacteremia) Kayexalate combined with D50 /insulin and/or IV calcium (for hyperkalemia) Valproic acid (Valproate) Internal bleeding Status Asthmaticus Lanoxin/Digoxin Status epilepticus (or prolonged post-ictal state) Labetalol/Trandate Venomous snake bite Lasix/Furosemide multiple times *Noncompliance with meds for seizure patients is not considered critical care **Gastric Lavages for GI Bleeds is not a CC intervention ***COPD/Asthma Exacerbation with continuous neb/ 3 breathing tx AND admission KISS principle for physicians: 1 data + 1 intervention = Critical care
8 Cardiac Catheterization
9 CT Pulmonary Embolism
10 Teaching Hospital Attending must bill CC time in chart, not resident CC time can only be billed for time staff spends, not resident Not CC time: Teaching time at bedside Resident time alone at bedside
11 Teaching Hospital At our hospital there is very little CC time being billed in large part due to Residents doing so much of the work Staff reimbursement is salary, not RVU/performance based, thus there is no financial incentive to document S&W, level 1 trauma and large referral center, has staggeringly unimpressive CC time billed
12 Staff Privileges
13 Lidocaine cardiotoxicity -> Flash Pulmonary Edema
14 Pediatric ICU Critical Care
15 Pediatric ER Critical Care
16 Facts About 3-6% of E/M codes depending on type of ED RVU (Relative Value Unit): MFS (Medicare Fee Schedule): $ RVU: MFS: $ (Medicare only) National 7.15% CO: 6.54% TX: 8.18% CA-S: 10.65% KS: 5.06%
17 Perfect World Documentation to include: Organ system at risk is What and why as far as diagnostic and/or therapeutic interventions undertaken Critical lab/imaging/ekg finding documented and significance addressed ED Course reflects frequent re-assessments and decision making Likelihood of life-threatening deterioration
18 Flags for audits 2+ hours of cc time billed Questionable medical necessity High frequency providers
19 Medicaid Population
20 Early Fournier s Gangrene
21 Example 1 ED Course: 14:10 Patient arrived in ED. 14:15 Ventilator:VT 480 ml,ac 16 increased to 20,Peep 5,O2 100%,Sat 98%. 14:16 Inserted 20 gauge right wrist. jp 14:16 Physician inserted central line. of Introducer (Cordis) in right femoral. dr 14:19 Assisted provider with ultrasound in room. 14:30 Physician inserted central line. of Quad lumen in right internal jugular. dr 14:30 Physician inserted arterial line. Sy 14:35 Foley cath inserted 15:00 Nasogastric tube inserted 14:20 15:35 L NS, norepinephrine gtt, IV KCl, 3amp bicarb, bicarb gtt, propofol gtt, protonix + protonix gtt 16:37 Norepinephrine ecreased to 4 mcg/min per Dr. Ramage 17:42 Admitted to intensive care unit,
22 Example 1 Critical Care Time: 15:57 Critical care time: Bedside Care: 20 minutes, Consultation: 5 minutes, Family Intervention: 5 minutes. Total time: 30 minutes daf 16:50 Critical care time: Bedside Care: 45 minutes, Consultation: 10 minutes, Family Intervention: 5 minutes. Total time: 60 minutes dr4
23 Happy Nurse, Happy Life
24 Subclavian CVC (Central Line)
25 Femoral Arterial Line
26 Femoral CVC
27 Bear Hugger
28 Example 2 ED Course: 17:08 Patient arrived in ED. 17:22 1L NS, TDaP vaccination, Ancef 2g IV, fentanyl 100mcg IV 17:32 O2 via nasal 4L/min. 18:29 I performed a bedside FAST exam, only lung exam performed, no ptx appreciated. 19:18 Chest, 1 View, Portable In Process Unspecified. 19:24 CT Chest (Mass, Trauma) In Process Unspecified. 19:24 CT Abd/Pelvis (trauma/abscess) In Process Unspecified. 20:29 Patient left the ED.
29 Example 2 Critical Care Time: 19:30 Critical care time: Bedside Care: 20 minutes, Consultation: 5 minutes, Family Intervention: 5 minutes. Total time: 30 minutes dr4
30 Right Thigh Puncture Wound with Expanding Hematoma
31 GF Induced Pneumothorax
32 Pneumothorax
33 Questions?
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