Can I bill Critical Care time?

[suckstobeme]

Trying to be better about billing CC time where appropriate.

I had a very stable NSTEMI. Moderately concerning story with normal EKG but elevated troponin. BP was a little high (170s/100s) but normalized with the nitro I gave for the pain. Labs otherwise unremarkable. Reviewed his last Stress/Echo/EKG. Started heparin. Did not call Cards. Admitted to Hospitalist. Between reviewing records, talking to family, documentation, reassess after nitro and all the other stuff probably around 30 minutes.

Would you bill for Critical Care? I usually don't for stable pts with a serious diagnosis, but I checked back on him two days after I admitted him and noticed the Hospitalist billed for critical care (I really have no idea for what though).

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[Groove]

If I start heparin gtt (or any drip for that matter), they get CC.

 

[RustedFox]

1. Get a list of CC billable diagnoses and their requirements.
2. Read and use it.
3. ?????
4. Profit.

 

[Angry Birds]

My feeling is that you can bill for critical care when you're not sure, and then the billers/coders can decide whether or not to use it. Not sure if this is sound advice though.

 

[southerndoc]

You answered your question with the fifth word of your second paragraph. Never bill critical care for any patient you document as "stable." If you're ever audited you will open yourself up to a lot of trouble.

CMS has allowed critical care for limb threatening injuries/problems in the past, but I've been told by our coders that this is no longer allowed. Likewise, two continuous nebulizer treatments don't automatically qualify for critical care anymore. If the patient is in respiratory distress, then it does.

A friend who works for CMS has stated they are targeting overbilling of critical care. Be careful. If it's unstable (even a severe dehydration with a heart rate of 140 is unstable and in distress), then bill for it if you spend >30 mins. If it's stable, then a level 5 is about all you can get.

 

[deleted859535]

My take is that if I feel there is a life-threatening etiology requiring treatment to optimize outcome, and there is a reasonable possibility of serious decline that is lessened by your management, then I chart CCT if my reportable involvement is greater than 30 minutes even if, case depending, they were hemodynamically stable in the ED.

Whether our billing company bills it accordingly is up to them. Happily, I assume they then would be involved in any audits.

NSTEMI with treatment like that, fractures/dislocations with severe skin tenting about to become an open fracture necessitating IV antibiotics/admission/emergent surgery that I then immediately address to prevent, severe asthmatics I'm able to turn around enough to discharge but take a boatload of bronchodilation/magnesium/steroids to do it, serious lactic acidosis requiring liters of crystalloid and medical admission to further treat -- I feel like some of this is in the grey area of CCT billing, but if I can in good faith apply my little rule of thumb above, I'll record CCT with a detailed MDM or explicit comment as to why I included CCT.

 

[Janders]

(1) Janders #1 rule of thumb for cc-- If I am putting someone on a drip, aside from NS, VERY high likely they are critical care.

(2) Have you read CPT's/CMS' actual critical care guidelines? I would if I were you. You are jaded, like most ED docs, and think critical is routine. This patient has an NSTEMI with a positive troponin, I would NOT label him STABLE I would call him "serious" or "guarded" at best.
"...currently defines a critical illness or injury as an illness or injury that 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..."
"Critical care services are defined as a physician's direct delivery of medical care for a critically ill or critically injured patient. It involves decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient's condition. Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure."

CMS adds that in order to qualify as critical care for Medicare patients, "the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient's condition".

(3) Cribbed from else where:
"Chest Pain (Unstable Angina or Acute Coronary Syndrome) TWO or more of the following: • Nitro drip, (being adjusted) • Transfer to cardiac center • TPA or Integrilin administered • New changes on EKG (i.e. ischemia, injury)(ST segment depression or elevation) • CT scan (look for other causes of pain) • Cath lab • Pulmonary edema • Positive Troponin (Elevated) • Heparin or Lovenox"


So in summary you have an Acute MI, in a patient who required complex medical decision making, treatment of a hypertensive emergency with nitro glycerin, immediate dosing of ASA and initiation of a heparin iv gtt to prevent worsening ischemia, MI, with likely CHF/Cardiac arrest without your expert intervention. Don't sell yourself short.

Read the ACEP guide to cc billing at the least

 

[RustedFox]

(1) Janders #1 rule of thumb for cc-- If I am putting someone on a drip, aside from NS, VERY high likely they are critical care.

(2) Have you read CPT's/CMS' actual critical care guidelines? I would if I were you. You are jaded, like most ED docs, and think critical is routine. This patient has an NSTEMI with a positive troponin, I would NOT label him STABLE I would call him "serious" or "guarded" at best.
"...currently defines a critical illness or injury as an illness or injury that 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..."
"Critical care services are defined as a physician's direct delivery of medical care for a critically ill or critically injured patient. It involves decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient's condition. Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure."

CMS adds that in order to qualify as critical care for Medicare patients, "the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient's condition".

(3) Cribbed from else where:
"Chest Pain (Unstable Angina or Acute Coronary Syndrome) TWO or more of the following: • Nitro drip, (being adjusted) • Transfer to cardiac center • TPA or Integrilin administered • New changes on EKG (i.e. ischemia, injury)(ST segment depression or elevation) • CT scan (look for other causes of pain) • Cath lab • Pulmonary edema • Positive Troponin (Elevated) • Heparin or Lovenox"


So in summary you have an Acute MI, in a patient who required complex medical decision making, treatment of a hypertensive emergency with nitro glycerin, immediate dosing of ASA and initiation of a heparin iv gtt to prevent worsening ischemia, MI, with likely CHF/Cardiac arrest without your expert intervention. Don't sell yourself short.

Read the ACEP guide to cc billing at the least

Let me make this easier for you: Chest pain + Elevated TnI + Lovenox/Heparin + admit = 30 min CC time.

 

[Janders]

Let me make this easier for you: Chest pain + Elevated TnI + Lovenox/Heparin + admit = 30 min CC time.

Teach a man (or woman) to fish...

 

[gamerEMdoc]

My antena goes up to consider billing cc when:

1. Nurse says “we need a doc in room x right now”
2. Anyone goes to the icu, gets intubated, gets a line, etc
3. Im managing arrythmias with medications (rapid afib) or actual electricity
4. A patient is on drips other than saline
5. A patient is getting blood transfusion for acute blood loss
6. A patient gets tpa
7. Patient is put on bipap for respiratory failure

Im sure there are more but those are the most common reasons that trigger me to think of cc time off the top of my head.

 

[deleted547339]

You answered your question with the fifth word of your second paragraph. Never bill critical care for any patient you document as "stable." If you're ever audited you will open yourself up to a lot of trouble.

CMS has allowed critical care for limb threatening injuries/problems in the past, but I've been told by our coders that this is no longer allowed. Likewise, two continuous nebulizer treatments don't automatically qualify for critical care anymore. If the patient is in respiratory distress, then it does.

A friend who works for CMS has stated they are targeting overbilling of critical care. Be careful. If it's unstable (even a severe dehydration with a heart rate of 140 is unstable and in distress), then bill for it if you spend >30 mins. If it's stable, then a level 5 is about all you can get.

Disagree. Stability is in the eye of the beholder. I have patients in my icu on two pressors that I call “stable” in my sign out - I will still bill critical care time on this when I finish fellowship next year.

How you state your MDM matters a lot. Unstable coronary plaque at high risk of decompensation, cardiogenic Shock, cardiac arrest and death. Serial EKGs. Stabilized hypertensive emergency via sublingual ntg. DAPT and hep gtt to aid in plaque stability. Tele. Airway and defibrillation equipment immediately available. Frequent reassessments as below. Will admit with cards consult for expected urgent cath.

That feels a lot like critical care....

 

[southerndoc]

Let me make this easier for you: Chest pain + Elevated TnI + Lovenox/Heparin + admit = 30 min CC time.

I agree, as long as you don't mark the patient as stable. They are not stable as they have a high risk of arrhythmia and decompensation.

 

[southerndoc]

Disagree. Stability is in the eye of the beholder. I have patients in my icu on two pressors that I call “stable” in my sign out - I will still bill critical care time on this when I finish fellowship next year.

How you state your MDM matters a lot. Unstable coronary plaque at high risk of decompensation, cardiogenic Shock, cardiac arrest and death. Serial EKGs. Stabilized hypertensive emergency via sublingual ntg. DAPT and hep gtt to aid in plaque stability. Tele. Airway and defibrillation equipment immediately available. Frequent reassessments as below. Will admit with cards consult for expected urgent cath.

That feels a lot like critical care....

Doesn't matter how you view them. Bill CMS for critical care and mark them stable and you run the risk of fraud.

To the person who stated that coders are involved and would be involved in an audit, keep in mind that CMS holds the physician accountable.

 

[deleted859535]

Doesn't matter how you view them. Bill CMS for critical care and mark them stable and you run the risk of fraud.

To the person who stated that coders are involved and would be involved in an audit, keep in mind that CMS holds the physician accountable.

That was me. Certainly. I just mean it'd help navigate that mess at least a small amount. And on charting, I tend to avoid the term "stable" if documenting CCT except where stating they were stable but made that way by me because they hit the door/EMS bay unstable -- and even if the vitals/etc make it seem that they were "stable" in a sense from the start, the possibility of decline is significant and mitigated by what I did.

I do tend to struggle with the desensitization of our specialty as someone alluded to above. For instance, charting CCT on a hypoxic bronchiolitis/asthmatic/influenza/pneumonia kiddo. I never feel like it's "critical" but this technically hypoxic child fighting to stay even in the high 80s% and retracting on RA is at risk of worsening unless I treat to improve, especially so if they're requiring oxygen now. It's not as obvious as the septic shock patient if it's "easily" fixed, but I sure feel like it counts. Part of the reason why I sometimes include a CCT indication in my note if it's not blatantly obvious (e.g., "acute hypoxic respiratory failure requiring such-and-such with supplementary oxygen" or what have you).

 

[Angry Birds]

To the person who stated that coders are involved and would be involved in an audit, keep in mind that CMS holds the physician accountable.

That was me who said that. I guess I gave pretty crappy advice. But, I really have a hard time believing that this would be a big deal if I accidentally put "critical care" on a few charts that didn't deserve it. The key term being "accidentally." Especially since I don't get paid any differently whether or not I bill more or less. I put CC down if I think it might fall under CC and if I remember to do so. I probably miss out on CC more often anyways (false negative) than putting it down incorrectly (false positive). Shrug.

I wonder if this is an overblown issue... Unless you are like systematically and maliciously trying to upcode everyone to a ridiculous extent.

 

[Groove]

Where is everyone getting this "stable" != CC but "serious, unstable, guarded, etc.." == CC ??

Have you had coders tell you this specifically or do you know definitively that it precludes CC? I don't see a requirement for "clinical status" or "stability" which I often document as "stable" from a hemodynamics standpoint. Personally, I don't like sending a pt out of the ED "unstable" on my chart, unless it's legit and there has been a massive resuscitation with continued hemodynamic instability. I always feel that it implies the pt wasn't maximally stabilized or infers that there was "other" management that the pt could have received but didn't that would have potentially "stabilized" them prior to admission, transfer, etc..

I can have a UGI bleed on protonix gtt, s/p PRBC that is VERY hemodynamically stable that I will document as such, but have absolutely no problem billing for CC. I would dare someone to try to deny the 99291 on that chart. I think a lot of this has to do with context, diagnosis, MDM, etc.. rather than resting solely on what box I checked under "clinical status". Sure, maybe "guarded" is more appropriate than "stable" but should it even really matter on that chart?

 

[BoardingDoc]

Where is everyone getting this "stable" != CC but "serious, unstable, guarded, etc.." == CC ??

Agree. I would love to know where this is coming from. As a concept it doesn't even make sense to me. I'm not saying that coding regulations make sense, but unless someone has some documentation that says stable != CC, I don't buy it.

As for the first question... absolutely critical care time. Are you really worried about getting audited on this one? I would simply say "he had a heart attack. a HEART ATTACK. How is that not a critical condition?" Just because it was a minor one is irrelevant.

 

[southerndoc]

You can document stable at discharge, but you need a documentation of unstable condition or being in distress at some part of your note. Perhaps I was not clear with that.

I'm saying you can't document stable and leave it at that. Conditions change. If you document somebody as in distress on your initial evaluation but document their admission status as stable, then that's two different things. You've clearly made them better and have distressed or unstable in your initial evaluation to document that critical care was warranted. If you document no distress/stable in your initial assessment and stable in your disposition, that is when you are going to have problems during an audit.

Sorry for the confusion.

 

[RoyBasch]

At least in my EMR the option "guarded" is available in the options for dispo condition. So for my typical ICU player or anyone with a real significant disease (such as a type I NSTEMI) I usually check "guarded" rather than unstable or stable even if they are hemodynamically and respiratory stable at the point of disposition.

I am in agreement with General Veers, I reserve "unstable" for a patient who is truly unstable and cannot be further stabilized even after significant resuscitation in the ER. Example: septic shock/ARDS now on intubated on the vent, several liters of fluid, multiple pressors, with ongoing hypotension rolling to the ICU. I reserve "critical" status for patients that are unstable and cannot be further stabilized in the ER because they require an emergent procedure (examples: GSW to the abdomen going to the OR for an ex-lap, STEMI going to the cath lab, massive UGIB that needs immediate EGD and banding).

In my MDM/reassessment for many routine sick patients such as shock now with stable BP after fluids and pressors or respiratory failure now sating well with NIPPV or intubation and MV I document that at the time of transfer of care and disposition they are in "stabilized critical condition." That being said, my final click box condition at the end of the chart for this type of patient will be "guarded."

With regards to being unable to bill critical care time unless "unstable" is selected in the disposition condition; I believe this is false. Our group has frequent education on critical care billing, and the long story short is that any condition that requires multiple reassessments, continuous infusion of medication besides routine IV fluids (so really any gtt including heparin), or has the potential to rapidly decompensate qualifies as critical care.

The coders at my hospital have informed me that even an alcohol intox patient that requires continuous pulse oximetry monitoring and you document at least 2 reassessments could qualify for critical care. Note, this seems sketchy to me and I would not bill CC on these patients.

To answer the original question, I think a suspected Type I NSTEMI (i.e. not demand ischemia elevated trop) DEFINITELY qualifies for CC. I also bill CC on all PE cases as well (I always start the heparin gtt in the ER)

 

[gamerEMdoc]

I don't think CC time has anything to do with the patient's stability on disposition. They can be stable when you admit them. Because you stabilized them when they were in critical condition.

For instance, an asthmatic with a sat of 80% gasping for air who gets continuous nebs, solumedrol, magnesium, bipap... then turns around and looks great and you send to a telemetry bed with a normal sat and smiling. That's critical care. The CPT definition for CC has nothing to do with stability when they are dispositioned.

Directly from ACEP:
"CPT currently defines a critical illness or injury as an illness or injury that 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."

All the patient has to have is an organ system impaired (like inability to breath) and high probability of badness if you don't intervene. This applies to a lot of things that are stable after we intervene. A hypotensive GI bleed who looks great after blood. A patient who comes in talking and is in Vtach who you cardiovert and is now assymptomatic. A bad COPD/acute decompensated CHF/Asthma patient. All of these cases, and many more, have a good probability of getting much worse and potentially deadly if we don't intervene. How many flash pulmonary edema patients come in hypertensive, diaphoretic and about to die, look great and are smiling and rock solid stable after BIPAP and afterload reduction? Just about all of them. But that doesn't mean they weren't critical when you intervened.

 

[SalemK]

My understanding is that you can absolutely have a "stable" patient who needs critical care time, but using the word itself in your documentation is a billing no-no. Even things like H/H should not be noted as stable, though you may write "within normal limits" or "no indication for transfusion."

 

[Apollyon]

There was a guy with whom I worked who was IM, and worked exclusively in the Chest Pain Center. He billed something like 60% CC, because chest pain could be like the guidelines state, even if the pts weren't admitted. He REALLY knew how to do it. Ironically, he was killed in a motorcycle accident.

 

[BoardingDoc]

There was a guy with whom I worked who was IM, and worked exclusively in the Chest Pain Center. He billed something like 60% CC, because chest pain could be like the guidelines state, even if the pts weren't admitted. He REALLY knew how to do it. Ironically, he was killed in a motorcycle accident.

How is that ironic?

 

[BAM!]

Easy, acute MI = critical care.

 

[Apollyon]

How is that ironic?

If you met him, you would not picture a Harley guy. Also, he billed more critical care than anyone else, and he was the only one to be a critical care patient out of our group of 60 or so (although, he wasn't actually a patient when he died, because he was killed at the scene).

 

[Brahnold Bloodaxe]

There was a guy with whom I worked who was IM, and worked exclusively in the Chest Pain Center. He billed something like 60% CC, because chest pain could be like the guidelines state, even if the pts weren't admitted. He REALLY knew how to do it. Ironically, he was killed in a motorcycle accident.

Reason #123,348 why driving a 12 year old Honda and vacationing at a lake 20 miles from the hospital to maximize dat retirement is penny wise and pound foolish. Life doesn't start at 60.

Forgive the tangent lol.

 

[Pudortu]

Do you guys know of any conferences or websites to help with our personal documentation to increase billing and make sure we hit critical care?

 

[Groove]

I had a TAA with concomitant Type A&B dissection yesterday on an esmolol drip. I put "critical" just to appease all your CC nazi hooligans. 🙄😀

 

[The White Coat Investor]

As a general rule, emergency docs underbill for critical care. If there's any doubt, claim it and let the coders/billers sort it out. If you claim it but it doesn't qualify, the coders/billers won't try to get it. If you don't claim it but it does, you just have less money to send junior to college.

It helps if you think about it this way: If this walked into a primary care doctor's office, would it come to you by ambulance? If so, it's probably critical care. An MI, a stroke, bad asthma, hypotension, hypoglycemia etc.

We get into this mindset that just because it was easy for us to fix a problem it couldn't have been life threatening. We minimize what we do. But an insulin drip or a heparin drip or multiple albuterol treatments or IM epi or IV glucose are all big deals.

 

[gamerEMdoc]

Do you guys know of any conferences or websites to help with our personal documentation to increase billing and make sure we hit critical care?

AAEM used to have a coding pre-conference the day before their scientific assembly every year. I’m not sure if they still offer it, but it was really good whenever I sat through at six or seven years ago.

I really wish this was something more residencies taught their residents. I lecture on the basics of billing and coding every year to the residents. It never fails, every year at least one graduating resident from the year before emails me to tell me that they have one of the highest rvu bonuses in their group.

EM coding isnt hard, its actually pretty simple outside of the medical decison making. ED docs can consistantly leave money on the table by undercharting their encounters, lack of cc billing, and poor documentation of procedures. It’s a really important skill that really should be stressed more in training, Id venture to say many US residency graduates have no idea about the ins and outs of how a chart gets coded.

 

[jm192]

(1) Janders #1 rule of thumb for cc-- If I am putting someone on a drip, aside from NS, VERY high likely they are critical care.

(2) Have you read CPT's/CMS' actual critical care guidelines? I would if I were you. You are jaded, like most ED docs, and think critical is routine. This patient has an NSTEMI with a positive troponin, I would NOT label him STABLE I would call him "serious" or "guarded" at best.
"...currently defines a critical illness or injury as an illness or injury that 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..."
"Critical care services are defined as a physician's direct delivery of medical care for a critically ill or critically injured patient. It involves decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient's condition. Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure."

CMS adds that in order to qualify as critical care for Medicare patients, "the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient's condition".

(3) Cribbed from else where:
"Chest Pain (Unstable Angina or Acute Coronary Syndrome) TWO or more of the following: • Nitro drip, (being adjusted) • Transfer to cardiac center • TPA or Integrilin administered • New changes on EKG (i.e. ischemia, injury)(ST segment depression or elevation) • CT scan (look for other causes of pain) • Cath lab • Pulmonary edema • Positive Troponin (Elevated) • Heparin or Lovenox"


So in summary you have an Acute MI, in a patient who required complex medical decision making, treatment of a hypertensive emergency with nitro glycerin, immediate dosing of ASA and initiation of a heparin iv gtt to prevent worsening ischemia, MI, with likely CHF/Cardiac arrest without your expert intervention. Don't sell yourself short.

Read the ACEP guide to cc billing at the least

Bumping this thread rather than starting a new one.

Basically, my question is if you have a patient on vasopressors--I would logically think that continuing those, evaluating that patient, titrating it one way or the other, etc counts as CC. However with the bolded above--I've already urgently initiated pressors previously. So is it no longer Critical care if they're still on pressors for subsequent days?

 

[BoardingDoc]

Bumping this thread rather than starting a new one.

Basically, my question is if you have a patient on vasopressors--I would logically think that continuing those, evaluating that patient, titrating it one way or the other, etc counts as CC. However with the bolded above--I've already urgently initiated pressors previously. So is it no longer Critical care if they're still on pressors for subsequent days?

This is the EM forum. Your question sounds like it is geared towards the ICU. That said, I would argue that any patient whose hemodynamic stability is pressor dependent is critically ill and you should document CC time on them.

 

[thegenius]

Trying to be better about billing CC time where appropriate.

I had a very stable NSTEMI. Moderately concerning story with normal EKG but elevated troponin. BP was a little high (170s/100s) but normalized with the nitro I gave for the pain. Labs otherwise unremarkable. Reviewed his last Stress/Echo/EKG. Started heparin. Did not call Cards. Admitted to Hospitalist. Between reviewing records, talking to family, documentation, reassess after nitro and all the other stuff probably around 30 minutes.

Would you bill for Critical Care? I usually don't for stable pts with a serious diagnosis, but I checked back on him two days after I admitted him and noticed the Hospitalist billed for critical care (I really have no idea for what though).

If you have him more than 1 sl nitro, I would probably bill for critical care time. But that one is a tough call.

Not that it matters all that much, but I tend to be more liberal with CC time if the lab value is high like potentially scary, like trop 0.8 or k+ 6.3.

There is a guy at my work who bills CC all the time. If your SpO2 is 92 or less he just bills it. claims "hypoxia" it's ridiculous

 

[thegenius]

If you have him more than 1 sl nitro, I would probably bill for critical care time. But that one is a tough call.

Not that it matters all that much, but I tend to be more liberal with CC time if the lab value is high like potentially scary, like trop 0.8 or k+ 6.3.

There is a guy at my work who bills CC all the time. If your SpO2 is 92 or less he just bills it. claims "hypoxia" it's ridiculous

EDIT
DOH!!!!!! Didn't realize this was a bumped thread. Sorry

 

[littlejuan]

How is that ironic?

Like rain on your wedding day

 

[BoardingDoc]

Like rain on your wedding day

Also not ironic. Literally everything in that song is simply an unfortunate occurrence and is not an example of irony. Alanis might have been a popular singer, but an English major she was not.

 

[gamerEMdoc]

The patient doesn't need to be dying to bill critical care. They have to have "a high probability of imminent or life-threatening deterioration in the patient’s condition” if you don't intervene. Meaning, if you didn't do anything to the patient, they could crump or die. So yes, having anyone on pressors is critical care time, assuming you spent more than 30 min with the case.

 

[littlejuan]

Also not ironic. Literally everything in that song is simply an unfortunate occurrence and is not an example of irony. Alanis might have been a popular singer, but an English major she was not.

... that was the joke! :/

 

[BoardingDoc]

... that was the joke! :/

I figured you were aware (as I hope most people are). This was just a pet peeve of mine around the time the song came out and I still can't help ranting about it when it comes up nowadays.

 

[deleted109597]

ED Charting and Coding: Critical Care Time
Yes. Do it.

 

[southerndoc]

Trying to be better about billing CC time where appropriate.

I had a very stable NSTEMI. Moderately concerning story with normal EKG but elevated troponin. BP was a little high (170s/100s) but normalized with the nitro I gave for the pain. Labs otherwise unremarkable. Reviewed his last Stress/Echo/EKG. Started heparin. Did not call Cards. Admitted to Hospitalist. Between reviewing records, talking to family, documentation, reassess after nitro and all the other stuff probably around 30 minutes.

Would you bill for Critical Care? I usually don't for stable pts with a serious diagnosis, but I checked back on him two days after I admitted him and noticed the Hospitalist billed for critical care (I really have no idea for what though).

If you give heparin or LMWH, then it qualifies as critical care. Any NSTEMI or PE has a life-threatening diagnosis that could result in imminent death if not treated.

 

[Lawpy]

If you give heparin or LMWH, then it qualifies as critical care. Any NSTEMI or PE has a life-threatening diagnosis that could result in imminent death if not treated.

Is this an updated answer? Because earlier, you said:

You answered your question with the fifth word of your second paragraph. Never bill critical care for any patient you document as "stable." If you're ever audited you will open yourself up to a lot of trouble.

CMS has allowed critical care for limb threatening injuries/problems in the past, but I've been told by our coders that this is no longer allowed. Likewise, two continuous nebulizer treatments don't automatically qualify for critical care anymore. If the patient is in respiratory distress, then it does.

A friend who works for CMS has stated they are targeting overbilling of critical care. Be careful. If it's unstable (even a severe dehydration with a heart rate of 140 is unstable and in distress), then bill for it if you spend >30 mins. If it's stable, then a level 5 is about all you can get.

Sorry got confused

 

[southerndoc]

Yes, I'm confused too. What are you saying is an updated answer to what I said? An NSTEMI or a PE shouldn't be marked as "stable" or not distressed. At best they are fair when they are admitted, but most are serious when admitted.

Am I missing something?

On another note, had a transfer the other day where the ED doc billed critical care time of 40 minutes for a simple fall with resultant intertrochanteric fracture of the hip. Normal vital signs, no distress, only received 2 mg of morphine for pain control. No labs checked either.

 

[Birdstrike]

Old thread but I'll weigh in anyways, since someone bumping it.

If you're admitting a patient with a myocardial infarction, in any form, you can bill critical care. A myocardial infarction is a threat to life. The only reason not to bill critical care in that setting is your own failure of documentation. Having an MI is enough. They don't need to lose pulse, they don't need to go into V tach, they don't need to have unstable vitals. Dying heart muscle is a critical illness. Period.

You're not going to get arrested and sent to jail for insurance fraud because some coder thinks your heart attack patient wasn't having a heart attack that was "bad enough" for them to pay for more than a level 5. If you bill all your sore throats as critical care to defraud the system hoping no one catches it, or bill for procedures you didn't do, then I'd be worried. But MIs: fire away.

MIs, tachy/brady arrythmias, syst BP <90/>200, any life or limb threats, are critical care until proven otherwise. Insurance companies have no leg to stand on if they deny payment on these and there's a near zero chance of a fraud charge if billed because you have objective proof they're extremely sick with a life/limb threat. At best, they could try to knock these down to a level 5, but they know that trying to say MIs are "sick enough" isn't where the low hanging fruit is, for them.

 

[aafisahar]

I've heard most heart failure exacerbations can be billed at critical care time; for example, someone comes in, needs 2-4L oxygen over a baseline of zero, volume overloaded, you can bill this as critical care time even though it seems fairly routine to us. Same with COPD exacerbations with new or increased O2 requirements, especially if you go hunting for a cause. They need not be hemodynamically unstable.

I think everyone agrees that pressors, pan-scans, head bleeds, are worthy of critical care time. It's some of the other stuff like the above that is the gray area.

 

[deleted547339]

I've heard most heart failure exacerbations can be billed at critical care time; for example, someone comes in, needs 2-4L oxygen over a baseline of zero, volume overloaded, you can bill this as critical care time even though it seems fairly routine to us. Same with COPD exacerbations with new or increased O2 requirements, especially if you go hunting for a cause. They need not be hemodynamically unstable.

I think everyone agrees that pressors, pan-scans, head bleeds, are worthy of critical care time. It's some of the other stuff like the above that is the gray area.

I think you’re right. That being said, we all know that when you have a tiny traumatic subarachnoid that barely shows up on CT - that person will be fine unless you give them double strength heparin then beat them with a hammer. But the billers aren’t scrolling through the CT to see if there is shift....once you have that diagnosis and document accordingly, you’re probably covered.

 

[deleted859535]

I've heard most heart failure exacerbations can be billed at critical care time; for example, someone comes in, needs 2-4L oxygen over a baseline of zero, volume overloaded, you can bill this as critical care time even though it seems fairly routine to us. Same with COPD exacerbations with new or increased O2 requirements, especially if you go hunting for a cause. They need not be hemodynamically unstable.

I think everyone agrees that pressors, pan-scans, head bleeds, are worthy of critical care time. It's some of the other stuff like the above that is the gray area.

Absolutely. Everything you just said is CCT. Acute hypoxic respiratory failure. You actively managed CHF/COPD/etc to help stabilize and reduce likelihood of dangerous worsening. That's CCT. The moderate to severe asthmatic I give mag, nebs, and steroids to, and who turns around enough for discharge, is still CCT.

 

[gamerEMdoc]

We grossly underbill CCT. To get CCT, all you need is to meet 2 criteria:
1. High probability of significant or life threatening deterioration without intervention
2. Spent at least 30 min on the case

That's it. The patient doesn't have to go to the ICU. Heck, they don't even have to be admitted. These are the simplified things I tell residents in my billing lecture about when to consider CCT:
- Any admission to the ICU
- Anytime a nurse comes to get you and says “We need a doctor in room…”
- Anytime a patient gets TPA
- Patients who are put on any continuous medication drips
- Anytime you are transfusing blood products
- Anytime you are doing Invasive Procedures (Tube, CVP, etc) on patients, they probably are CCT candidates
- Any patient you put on BIPAP for respiratory distress

That's just a short list of things that prompt me to ask myself, should I bill CCT on this patient. None of these are absolutes, just something that prompts me to think about billing for CCT.

 

[deleted547339]

We grossly underbill CCT. To get CCT, all you need is to meet 2 criteria:
1. High probability of significant or life threatening deterioration without intervention
2. Spent at least 30 min on the case

That's it. The patient doesn't have to go to the ICU. Heck, they don't even have to be admitted. These are the simplified things I tell residents in my billing lecture about when to consider CCT:
- Any admission to the ICU
- Anytime a nurse comes to get you and says “We need a doctor in room…”
- Anytime a patient gets TPA
- Patients who are put on any continuous medication drips
- Anytime you are transfusing blood products
- Anytime you are doing Invasive Procedures (Tube, CVP, etc) on patients, they probably are CCT candidates
- Any patient you put on BIPAP for respiratory distress

That's just a short list of things that prompt me to ask myself, should I bill CCT on this patient. None of these are absolutes, just something that prompts me to think about billing for CCT.

I disagree with several of your statements above. As an example, Heparin for a DVT is a gtt but not critical care.

 

[gamerEMdoc]

I disagree with several of your statements above. As an example, Heparin for a DVT is a gtt but not critical care.

That's just a short list of things that prompt me to ask myself, should I bill CCT on this patient. None of these are absolutes

This is why I posted that exact qualifier below the list. This is merely a list of things of when to consider if you performed CCT. There are no absolute examples for what is or is not CCT. CCT is defined by the individual case. The only CMS definition of CCT is the one I posted about the high probability of deterioration and a minimum of 30 min. There is no further clarification from them beyond that. This is a list of things to prompt you to think, did I perform CCT or not. Not a list of what is CCT.

A heparin gtt being started on a saddle PE that you considered TPA on, talked to IR about catheter directed TPA, had to put on BIPAP, and admitted to the ICU is not the same thing as starting a heparin gtt on a patient with a DVT (why would anyone still use a heparin gtt on a simple DVT anyways?). A cardizem gtt on a stable rapid afib is not the same as a patient who presented hypotensive with rapid afib that you considered electrical cardioversion, gave a small bolus of IVF to, pretreated with calcium, then started on cardizem while standing buy with push dose pressors if they got hypotensive with the cardizem. Same medications, completely different cases.