Critical Care Billing and Coding in Emergency Medicine

Critical Care Billing and Coding in Emergency Medicine Darron Ramage MD March 11, 2013

Objectives  Definition  Teaching

Hospital Nuances

 Facts  Interactive

Examples

Disclosures  None

Intelligent Medicine by Design

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

Definition  

99291: 30-74 minutes 99292: each additional 30 minutes 



Includes:   



Ex) 120 min of critical care time would bill out: 99291, 99292 X 2 NG Tubes Transcutaneous Pacing Peripheral Venous Access

Excludes:      

Intubation CPR Central Line Cardioversion Chest tube Wound repair

Definition Exceptions noted within example stand alone as critical care; do not need both data and intervention; still need to meet DG Application & use of external, percutaneous or intracardiac pacemaker C1, C2 or C3 fracture - displaced and/or with neuro deficit CPR Intubation

Nipride IV Nitroglycerin/Tridil IV Nitroprusside IV Neosynephrine IV

Intracranial hemorrhage

Epinepherine IV/SQ

Data

Intervention

Abnormal Labs consistent with organ system failure Sat O2 (pulse ox) < 90% PCO2 > 60 PO2 < 60 Creat >2 Hemoglobin (Hgb) 250 Glucose (Gluc) accucheck Hi Glucose (Gluc) < 40 Ph < 7.25

Procedures (that are good inferences for critical care) Blood transfusion Admit/Xfer to cath lab Central lines Bipap or CPAP Chest tube ≥ 3 sequential breathing tx CPR Continuous Neb. Tx. Defibrillation/emergent cardioversion NG Lavage/Gastric Lavage Nitro Paste/Patch Pericardiocentesis Nitroglycerin SL x 3 or more Peritoneal lavage Thoracostomy NG Act. Charcoal/Act. Carbon

Sodium (Na) Potassium (K) Potassium (K)

24 Respirations (adult) < 10 Respirations (child)

Temperature (adult) Temperature Heart rate/pulse (adult)

> 20 sternal retraction, nasal flaring, cheyene stokes or tachypnea > 104° < 96° > 100

Heart rate/pulse (adult) Systolic BP (adult)

< 60 > 180

Systolic BP (adult)

< 90

Respirations (adult/child)

Diagnoses indicative of critical care Anaphylaxis

MI (*incl. STEMI/Non-STEMI) afib, vfib, vtach, aflutter, SVT with hypotension Organ system failure (or potential) Bradycardia (*w/Atropine therapy)

IV Resuscitation ( 2000cc/2 litres fluids)

Examples of IV medications: (Drip or push) Abx for sepsis or meningitis Levetiracetam (Keppra) Adenocard/Adenosine Levophed/Norepinephrine Aggrastat/Tirofiban Lidocaine Amiodarone Angiomax/Bivalirudin Atropine Cardene/Nicardipine HCL Cardizem/Diltiazem Corlopam/Fenoldopam Mseylate Crofab D50

Lopressor/Metoprolol lorazepam/Ativan Mannitol/Hexan Midazolam/Versed NaBicarb Narcan/Naloxone Natrecor/Nesiritide phenobarbitol/Phenobarbitone

Diazepam/Valium Dilantin

Pitocin/Oxytocin Potassium (K-rider)

Diprivan/Propofol Dobutamine

Procainamide/Pronestyl Retavase/Reteplase

Dopamine

Romazicon/Flumazepil

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) Hypo/hyperthemia

Respiratory failure Shock Sepsis (urosepsis/bacteremia)

Isuprel/Isoprenaline

Theophylline/Dimethylxanthine

Kayexalate combined with D50 /insulin and/or IV calcium (for hyperkalemia)

Valproic acid (Valproate)

Status Asthmaticus

Lanoxin/Digoxin

Hypoxia Internal bleeding 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

Cardiac Catheterization

CT Pulmonary Embolism

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

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

Staff Privileges

Lidocaine cardiotoxicity -> Flash Pulmonary Edema

Pediatric ICU Critical Care

Pediatric ER Critical Care

Facts        

About 3-6% of E/M codes depending on type of ED 99285 2013 RVU (Relative Value Unit): 4.93 2013 MFS (Medicare Fee Schedule): $167.73 99291 2013 RVU: 6.40 2013 MFS: $217.75 2011 (Medicare only)     

National 7.15% CO: 6.54% TX: 8.18% CA-S: 10.65% KS: 5.06%

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

Flags for audits…  2+

hours of cc time billed  Questionable medical necessity  High frequency providers

Medicaid Population

Early Fournier’s Gangrene

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,

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

Happy Nurse, Happy Life

Subclavian CVC (Central Line)

Femoral Arterial Line

Femoral CVC

Bear Hugger

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 cannula @ 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.

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

Right Thigh Puncture Wound with Expanding Hematoma

GF Induced Pneumothorax

Pneumothorax

Questions?