Can I bill Critical Care time?

[thegenius]

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.

I see that s**t all the time and it makes me mad. Makes me want to report them.

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[thegenius]

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.

We get these cheap pneumonias, healthy 55 yr old with SpO2 92%, otherwise normal vitals. They get IV Abx, 2L O2, and I've seen people bill critical care time for that. They go to the floor. I don't think there is anything critical about that patient.

Maybe that's why I make $75/hr less than they do.

 

[thegenius]

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.

Pan scans? For real?

It all depends, right? I sometimes pan scan because I'm too busy to play doctor (as much as I like being a doctor), so I'll let the radiologist give me the dx.

 

[Lawpy]

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.

No you're right. I got confused when I read it the first time since I thought there was a contradiction but I understood now. Thanks!

 

[aafisahar]

Pan scans? For real?

It all depends, right? I sometimes pan scan because I'm too busy to play doctor (as much as I like being a doctor), so I'll let the radiologist give me the dx.

The 74-year-old with a lactate of 6 giving zero history gets a pan-scan, at least on my side on IM.

 

[BoardingDoc]

The 74-year-old with a lactate of 6 giving zero history gets a pan-scan, at least on my side on IM.

I think @thegenius was more incredulous because pan-scans are pretty rare in the ED. I got them all the time during residency on trauma patients, but even then I wouldn't bill CC time on them unless I found something on the imaging. If you bill CC time because they're a "trauma who got pan-scanned" but had nothing wrong, I think that's absurd. For medical patients, I can't recall the last time I pan-scanned someone.

 

[Birdstrike]

I see that s**t all the time and it makes me mad. Makes me want to report them.

My guess is that the transfering ED doc felt that a fracture in need of emergency surgery, severe enough to require a tertiary transfer for emergency surgery for a limb threatening condition (useless limb, can't walk if not fixed) was what crossed the threshold from a level 5 to critical care. I'd call that aggressive billing, but fraudulent would be a long stretch. Could get reduced to a level 5, but there definitely is an element of criticality there.

 

[Birdstrike]

We get these cheap pneumonias, healthy 55 yr old with SpO2 92%, otherwise normal vitals. They get IV Abx, 2L O2, and I've seen people bill critical care time for that. They go to the floor. I don't think there is anything critical about that patient.

Maybe that's why I make $75/hr less than they do.

If the sat dropped below 90% that could easily trigger a justifiable critical care charge, in my opinion.

92%?

Let's see: If they billed critical care, and the insurance company denied payment, the argument on appeal would be that people die of pneumonia all the time, this patient had a severe enough case to require admission and although not overtly hypoxic, had impaired oxygenation. I'm more worried about a sat of 92% in a healthy patient that's normally 98%, than a 92% in a COPDer that normally runs 92%.

So I don't know what a coding expert would say on this one. I would be surprised if half said it was a legit critical care charge and half said its a level 5. Often times when billing, think in reverse. "If I missed this diagnosis and sent this patient home, could they desat and die from sepsis?"

If the answer is yes, that might change your thinking on the billing.

 

[Birdstrike]

I think @thegenius was more incredulous because pan-scans are pretty rare in the ED. I got them all the time during residency on trauma patients, but even then I wouldn't bill CC time on them unless I found something on the imaging. If you bill CC time because they're a "trauma who got pan-scanned" but had nothing wrong, I think that's absurd. For medical patients, I can't recall the last time I pan-scanned someone.

They had you guys doing the coding in residency?
I definitely think that's good learning, but man, I sure hope the group had a coder double checking the July interns' coding decisions.

 

[BoardingDoc]

They had you guys doing the coding in residency?
I definitely think that's good learning, but man, I sure hope the group had a coder double checking the July interns' coding decisions.

Sorry, that was poorly worded. I meant that I saw pan scanned patients as a resident often. Now, as an attending even if I pan-scanned someone, I would not bill CC time on them unless they had significant injuries.

As an aside, I did significant reading about coding charts during residency during my last year, however, this was largely self driven. I agree it would have been a useful part of the curriculum.