Charting for RVU maximization

[onlyletters]

First, just want to say thank you for all the wisdom gleaned from this community.

About to become an attending and have certainly realized I was not taught in residency to chart for maximum RVU harvesting such as charting 30minutes+ for critical care time, explicitly interpreting pulse oximetry, explicitly interpreting EKGs, etc.

I'll be working at a place where salary is dependent on RVUs.

Any charting tricks of the trade or suggestions to make sure I'm not leaving any RVUs on the table?

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[Groove]

Smoking cessation counseling 3-10m and >10m bills for 0.3 and 0.7 RVU respectively

 

[deleted109597]

Definitive fracture care. Document NVI after splint application. Put on your own splints.
Document heart monitor rhythm and pulse ox.
Interpret labs, don't just copy them.

 

[onlyletters]

Definitive fracture care. Document NVI after splint application. Put on your own splints.
Document heart monitor rhythm and pulse ox.
Interpret labs, don't just copy them.

In terms of interpreting labs, what counts? I'm guessing the normal chloride level doesn't need to be explicitly stated. Do you have to comments on every abnormality even if it's non-contributory or does something like "no leukocytosis, electrolytes grossly normal, negative troponin, and LFTs mildly elevated" count?

 

[RoyBasch]

Definitive fracture care. Document NVI after splint application. Put on your own splints.

Placing your own splint includes non-custom splints such as aircasts, knee braces ('Zimmer splints'), etc. Not just orthoglass/plaster custom splints. Document as a splint procedure note and as McNinja mentioned document post splinting neurovascular extremity exam. Easy money.

Also I am told, any critical care time LESS than 33 minutes does not count, so any and all critical care should be at least 33 minutes (no point in documenting 15, 20, 25 mins, etc. of CC time). This has been debated before on this forum, but the definition of acceptable billable CC is probably broader than most people think (any NSTEMI, more than 2L of fluid resuscitation, etc.) Check this forum for broader discussions. Bottom line, a lot of possibly billable CC time isn't captured by ER physician charts.

 

[thegenius]

Smoking cessation counseling 3-10m and >10m bills for 0.3 and 0.7 RVU respectively

You actually have to do this to get credit
obviously

we all barely spend 3 minutes in a room doing an H&P

However that being said, there is a doc I work with who puts in a "I counseled the pt on smoking cessation (if applicable) for more than 3 minutes" in every chart. He is one of our most productive docs. But I wonder if he actually gets credit for those CPT codes.

 

[Groove]

Placing your own splint includes non-custom splints such as aircasts, knee braces ('Zimmer splints'), etc. Not just orthoglass/plaster custom splints. Document as a splint procedure note and as McNinja mentioned document post splinting neurovascular extremity exam. Easy money.

Also I am told, any critical care time LESS than 33 minutes does not count, so any and all critical care should be at least 33 minutes (no point in documenting 15, 20, 25 mins, etc. of CC time). This has been debated before on this forum, but the definition of acceptable billable CC is probably broader than most people think (any NSTEMI, more than 2L of fluid resuscitation, etc.) Check this forum for broader discussions. Bottom line, a lot of possibly billable CC time isn't captured by ER physician charts.

Totally agree. I billed 11% 99291 this past month. Asthma exacerbations, HTN Crisis/Urgency, renal failure, strokes, nstemi, ectopic, surgical admissions (where they go emergently to the OR), any bipap, any drips, hypoglycemic episodes requiring D50, Psychotic patients requiring restraints/sedation, Overdoses, etc.. I would argue that suicidal patients also qualify. All types of stuff qualifies even if you discharge them home. I've been billing 8-14%/mo for years and have never been audited. I think CC billing is definitely under utilized in our specialty.

 

[Groove]

You actually have to do this to get credit
obviously

we all barely spend 3 minutes in a room doing an H&P

However that being said, there is a doc I work with who puts in a "I counseled the pt on smoking cessation (if applicable) for more than 3 minutes" in every chart. He is one of our most productive docs. But I wonder if he actually gets credit for those CPT codes.

I researched it awhile back and have some smart phrases with all the required mumbo jumbo. It's probably over kill but I know they can definitely bill for it. The RVUs add up. Here's what I use:

Smoking:

The patient was questioned about the use of tobacco products and subsequently identified as a SMOKER. As a result of this disclosure, I gave counsel regarding the health risk and hazards of tobacco abuse and the benefits of smoking cessation. Time was allotted to answer questions and to provide information regarding counseling/modalities for assistance with quitting. Counseling included identifying barriers to change, suggesting specific actions for change, motivational counseling and follow up instructions. Time spent: X mins.

I also have one for alcohol and drugs.

Alcohol:

The patient was questioned about the use of alcohol and utilizing the AUDIT-C screening tool was subsequently identified as at risk for alcohol abuse. As a result of this disclosure, I facilitated a structured assessment, brief intervention and followup for treatment in SBIRT format. I gave counsel regarding the health risk and hazards of alcohol abuse and the benefits of alcohol reduction/cessation. Time was allotted to answer questions and to provide information regarding counseling/modalities for assistance with quitting. Counseling included identifying barriers to change, suggesting specific actions for change, motivational counseling and follow up instructions. Time spent: X mins.

Drugs:

The patient was questioned about the use of drugs and utilizing the DAST screening tool was subsequently identified as at risk for substance abuse. As a result of this disclosure, I facilitated a structured assessment, brief intervention and followup for treatment in SBIRT format. I gave counsel regarding the health risk and hazards of drug abuse and the benefits of drug cessation. Time was allotted to answer questions and to provide information regarding counseling/modalities for assistance with quitting. Counseling included identifying barriers to change, suggesting specific actions for change, motivational counseling and follow up instructions. Time spent: X mins.

If you're going to do either of the alcohol and/org drugs, you have to document 15 mins, unlike smoking (3-10 or > 10). The easiest to justify in the ED is always going to be 3-10 mins smoking cessation counseling. There's no reason not to bill for this one guys and for the others...well sometimes I think it could also be justified given the right circumstance.

 

[thegenius]

Totally agree. I billed 11% 99291 this past month. Asthma exacerbations, HTN Crisis/Urgency, renal failure, strokes, nstemi, ectopic, surgical admissions (where they go emergently to the OR), any bipap, any drips, hypoglycemic episodes requiring D50, Psychotic patients requiring restraints/sedation, Overdoses, etc.. I would argue that suicidal patients also qualify. All types of stuff qualifies even if you discharge them home. I've been billing 8-14%/mo for years and have never been audited. I think CC billing is definitely under utilized in our specialty.

So you charge CC if you diagnose acute appendicitis, say they have normal vital signs, you start antibiotics, call GS, and they go to the OR within the next 2-3 hours? Hey if this is acceptable then I'm going to do it all the time. Same thing apply for uncomplicated acute cholecystitis? What about uncomplicated SBO?

Acute Pyelonephritis. HR 110, BP normal, Temp 99.9. You give them 1L IVF, tylenol, one dose of IV Abx. They are much better and can be discharged. I don't know if that patient was critically ill. Maybe.

Renal Failure. Suppose you get a pt who comes in weak and tired. 2 months ago their Cr was 1. Now it is 4. You aren't totally sure why, so you give them 1L NS, or say you start maintenance IVF. They obviously need to be admitted. You charge CC for that?

Just curious. Last year I was 6.8% which was kind of high in our group, we average 4-5% and our top guy averaged 8.5%.

 

[Groove]

I just incorporate the smoking cessation counseling into my history. How many patients do you have that tell you they smoke 4-5 cigarettes a day? I usually make a joke out of it and go "4-5?! Is that all?! Man, you're SO close to quitting, why not quit completely so we can keep you off oxygen later on in life?? I don't know how much those things cost but I bet you'd also save quite a bit of money, right?!", etc..

 

[thegenius]

I researched it awhile back and have some smart phrases with all the required mumbo jumbo. It's probably over kill but I know they can definitely bill for it. The RVUs add up. Here's what I use:

Smoking:

The patient was questioned about the use of tobacco products and subsequently identified as a SMOKER. As a result of this disclosure, I gave counsel regarding the health risk and hazards of tobacco abuse and the benefits of smoking cessation. Time was allotted to answer questions and to provide information regarding counseling/modalities for assistance with quitting. Counseling included identifying barriers to change, suggesting specific actions for change, motivational counseling and follow up instructions. Time spent: X mins.

Have you verified from your billing and coding company that you always get the RVU for smoking cessation? I'm just curious.

 

[thegenius]

I looked at my CPT codes once over a few months.

I never got anything for interpreting pulse ox. That's in every chart.

Most common CPT codes, besides 99281-99285 were
- Interpreting EKG 93010
- Critical Care 99291, 99292

Then there are those for
- orthopedic procedures like splints, reductions
- suturing

 

[Groove]

So you charge CC if you diagnose acute appendicitis, say they have normal vital signs, you start antibiotics, call GS, and they go to the OR within the next 2-3 hours? Hey if this is acceptable then I'm going to do it all the time. Same thing apply for uncomplicated acute cholecystitis? What about uncomplicated SBO?

Acute Pyelonephritis. HR 110, BP normal, Temp 99.9. You give them 1L IVF, tylenol, one dose of IV Abx. They are much better and can be discharged. I don't know if that patient was critically ill. Maybe.

Renal Failure. Suppose you get a pt who comes in weak and tired. 2 months ago their Cr was 1. Now it is 4. You aren't totally sure why, so you give them 1L NS, or say you start maintenance IVF. They obviously need to be admitted. You charge CC for that?

Just curious. Last year I was 6.8% which was kind of high in our group, we average 4-5% and our top guy averaged 8.5%.

1) Appendicitis or anything going emergently to the OR definitely counts. Remember, any condition where "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." counts. Don't overthink it. It's a surgical emergency, hence why they are going "emergently" to the operating room. If there wasn't worry for clinically significant OR life threatening deterioration, they wouldn't be going straight to surgery.

2) If you're going to call it clinical sepsis, then it qualifies. If you're going to call it acute pyelonephritis, then I wouldn't document CC time. All my dx for "sepsis" get CC time.

3) Organ failure counts. Renal failure is a commonly overlooked opportunity to bill CC time. I would recommend diagnosing "acute renal failure", not "renal insufficiency or AKI" if you plan on billing CC for this one.

I think national average is 8%, many in our shop bill for only 4-6% but think about it... We all work in emergency medicine. We deal with emergencies every shift. We really should be billing for more than 4-6% for "critical care" within our field. That's my opinion at least.

 

[Groove]

I looked at my CPT codes once over a few months.

I never got anything for interpreting pulse ox. That's in every chart.

Most common CPT codes, besides 99281-99285 were
- Interpreting EKG 93010
- Critical Care 99291, 99292

Then there are those for
- orthopedic procedures like splints, reductions
- suturing

I'm actually not sure about pulse ox interpretation. I do know it's bundled if you bill for CC. I document it sometimes but I'm not sure the coders can bill for it alone. You might ask whoever is in charge of quality or billing to look into it. I'd honestly be curious.

 

[Groove]

Have you verified from your billing and coding company that you always get the RVU for smoking cessation? I'm just curious.

Yes. Sometimes, coders miss stuff. If you have something that you feel they are missing, get in touch with whomever if in charge of coding/billing and educate them on a code you are wanting to use. They will tell you if you can't charge for it. I was having a similar issue recently where EZ IJs were being billed as central lines as well as plain EJs and were resulting in MIPS fallouts because the procedures weren't including the obligatory sterile technique, etc.. I've also had them miss 99292s and charge them as 291s, etc..

 

[thegenius]

1) Appendicitis or anything going emergently to the OR definitely counts. Remember, any condition where "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." counts. Don't overthink it. It's a surgical emergency, hence why they are going "emergently" to the operating room. If there wasn't worry for clinically significant OR life threatening deterioration, they wouldn't be going straight to surgery.

2) If you're going to call it clinical sepsis, then it qualifies. If you're going to call it acute pyelonephritis, then I wouldn't document CC time. All my dx for "sepsis" get CC time.

3) Organ failure counts. Renal failure is a commonly overlooked opportunity to bill CC time. I would recommend diagnosing "acute renal failure", not "renal insufficiency or AKI" if you plan on billing CC for this one.

I think national average is 8%, many in our shop bill for only 4-6% but think about it... We all work in emergency medicine. We deal with emergencies every shift. We really should be billing for more than 4-6% for "critical care" within our field. That's my opinion at least.

I hear ya man. The appendicitis thing I guess makes sense. I guess the intervention is getting the surgeon to take the patient to the OR. You (the ER doc) are doing things right now to prevent severe morbidity or mortality.

I see how organ failure counts...but what intervention are you doing right now? Giving 1L IVF? Hey if that means you get CC then I'm going to do it more. I don't know if a Cr from 1-4 over 2 months is "renal failure." Then again, you can have "heart failure" and still play tennis, according to one of my medical school teachers.

Regarding #2 above...
do you add an additional diagnosis of "sepsis"? Like in that case.. one diagnosis / CPT code would be "Acute Pyelonephritis". If the patient was septic, you know, met the definition of sepsis, would you add another diagnosis / CPT code called "Sepsis"?

 

[thegenius]

Hmm....
It just feels dirty billing for smoking cessation when it's not really done, know what I mean. I have thought over the past few years about putting it in all my charts. But then I tell myself it's like $10 bucks. Why would anyone complain about that? Why would they audit me over $10 bucks?

I wonder why the CPT people think smoking cessation counseling can be accomplished in 3 minutes, but drugs and alcohol counseling require 10 minutes?

 

[Groove]

Hmm....
It just feels dirty billing for smoking cessation when it's not really done, know what I mean. I have thought over the past few years about putting it in all my charts. But then I tell myself it's like $10 bucks. Why would anyone complain about that? Why would they audit me over $10 bucks?

I wonder why the CPT people think smoking cessation counseling can be accomplished in 3 minutes, but drugs and alcohol counseling require 10 minutes?

Well, it's only 3 mins. I think it's the motive that counts. If you're truly trying to counsel the pt to stop smoking, then I think you should get credit for that. CMS are the ones that should feel dirty for continually coming up with additional hoops and hurdles to prevent you from being compensated for your work.

 

[RoyBasch]

I routinely bill 10-15% critical care, so I feel I am capturing it fairly well with my documentation. As for these specific cases here's how I would manage:

So you charge CC if you diagnose acute appendicitis, say they have normal vital signs, you start antibiotics, call GS, and they go to the OR within the next 2-3 hours? Hey if this is acceptable then I'm going to do it all the time. Same thing apply for uncomplicated acute cholecystitis? What about uncomplicated SBO?

If the patient is not at least severely septic/shock from these conditions and not otherwise requiring multiple liters of fluid resuscitation, it would be a No for me. At my hospital these patients do not typically go to the OR for several hours (and never in the middle of the night).

OR cases that would always be CC for me would be any perforation with free air, any large free fluid in the abdomen such as a splenic rupture, bowel infarction or gynecologic catastrophe (ruptured ectopic or OB hemorrhage requiring blood products).

Acute Pyelonephritis. HR 110, BP normal, Temp 99.9. You give them 1L IVF, tylenol, one dose of IV Abx. They are much better and can be discharged. I don't know if that patient was critically ill. Maybe.

No.

Renal Failure. Suppose you get a pt who comes in weak and tired. 2 months ago their Cr was 1. Now it is 4. You aren't totally sure why, so you give them 1L NS, or say you start maintenance IVF. They obviously need to be admitted. You charge CC for that?

No. Unless they have an AEIOU-type emergency requiring immediate temporization such as treatment for hyperkalemia, NIPPV for respiratory failure from volume overload. I think if the patient you mentioned were to even eventually require HD, if it is not emergently coordinated from the ER but done later say HD#2 after pt fails to improve with fluids or whatever I probably wouldn't count. In this case the inpatient team is the one providing the critical care.

 

[AlmostAnMD]

When you put the smoking stuff in your chart, that's all you need? Not to put it in the clinical impression or something? A biller just picks it up reading your chart?

 

[thegenius]

Yea we've had these discussions before on here. There appears to be disagreement on how to bill for CC.

I think the renal failure I posed above is a good example...someone comes in because they are weak and tired. After talking to them, seeing their vitals (for sake of argument normal), and they have a normal physical exam...you are thinking to yourself "I'm going to get some labs, maybe a CXR, maybe a UA and if everything is negative they can go see their PMD. They do not appear critically ill." Low and behold their Cr went from 1 to 4 and their other labs are normalish. Maybe their K+ is 5.0. Maybe their Bicarb is 20. Maybe their Hg went from 14 to 11. All of these things can be seen with renal failure. But they are not critically ill right now, and they really don't have a likely chance of suffering severe morbidity or mortality in the next day or two. But they need an expeditious workup and in our health care system that means they are admitted for more tests, nephrology consult, and yada-yada. So I probably wouldn't bill CC for this.

But if someone does require immediate evaluation (like acute stroke symptoms, acute chest pain especially with EKG changes, poly-trauma, hypotension, blah blah), and whether they get immediate intervention or not...that is CC time. So if your acute stroke symptom ends up being a plain-old UTI, you get CC time. If that full trauma activation just got lucky and only has road rash and no internal injuries...you get CC time.

Even then...there are these "eh...cases"
Like pt comes in with palpitations. No pain. No SOB. Been going on for 1 week. They have Afib with RVR 120-135. BP is 140-90. Now I would check labs and maybe give a dose of diltiazem IV. Now their HR is 95-105. They are fine. They need an outpatient workup. Discharge them with appropriate meds and followup.
In reality they don't even need IV dilt. You could start them on metoprolol 100 mg XR.
Now I can't remember if you do two IV pushes of rate control agents, that is considered CC?
Some docs I have will push lopressor 2.5 mg IVP for afib with RVR 110. Just so they can push it twice and charge CC. I read their chart and there is nothing to suggest they are in distress at all. Or critically ill. They don't even say "pt is potentially critically ill immediately requiring a piss-tiny dose of lopressor."

Not all hypoxia is critical care, right? 93% RA is hypoxia (or hypoxemia rather...). That ain't that bad. 88% is, or 82% is.



At the end of the day, you can dress up a chart and make someone appear very sick when they are not. That is a skill. If you make them appear very sick, easier to charge CC.

 

[thegenius]

When you put the smoking stuff in your chart, that's all you need? Not to put it in the clinical impression or something? A biller just picks it up reading your chart?

Yup...biller spends many minutes looking at your chart. Finding everything you can bill for.

 

[Arcan57]

Work part time or locums at several shops on an RVU basis. Bill crit care on 30-50% of your charts. You won’t be seeing enough patients to completely throw off the shops overall percentage, it will take months before anyone really notices, and that notice will be a chat with FMD noting that your CC % is too high (which you’ll counter by making up the story of some horrible shift knowing that haven’t pulled all your charts for an initial sit down). Theoretically.

 

[deleted109597]

3) Organ failure counts. Renal failure is a commonly overlooked opportunity to bill CC time. I would recommend diagnosing "acute renal failure", not "renal insufficiency or AKI" if you plan on billing CC for this one.

CHF absolutely counts. STEMI would if they stayed in the department long enough.
In AKI/CKI, one that is nearly automatic CC is hyperK. It will kill them dead, you need to treat it. Ipso facto CC time.
I will document CC time less than 34 minutes. Just to stay in the habit and in case of any audit, I can show that I in fact do not only ever document it for billable time.
I'm around 8% now (slighly lower acuity), but was 10-11% at my last shop. There would be times I would bill on 4-5 patients on a shift, then towards the end a sick one would come in and I would have to think in my head whether I could bill CC or not. You never want to bill more time than you actually worked, and if you bill 8 hours out of 10, and they see that you've taken care of 10 other patients during the shift, then questions get raised if you were actually providing 1 on 1 care during that time you documented. Neither CMS nor the IRS has audited me, but I don't want to live in fear of it.

 

[deleted109597]

In terms of interpreting labs, what counts? I'm guessing the normal chloride level doesn't need to be explicitly stated. Do you have to comments on every abnormality even if it's non-contributory or does something like "no leukocytosis, electrolytes grossly normal, negative troponin, and LFTs mildly elevated" count?

Literally just normal or abnormal. You don't even need to say which direction it's abnormal in. Writing it doesn't count, saying it is abnormal (without writing it) does.

 

[deleted547339]

Intensivist here - just remember that your critical care time is all encompassing. If you have a patient with a critical illness, you basically can’t spend less than 30 minutes doing it. It includes time spent doing the your H&P, putting in orders, talking to consultants, talking to family, documenting, etc. yes, a STEMI May only be in your ED for 15 minutes, but if you took the prehospital call, called IC, put in orders, read the EKG, talked to the patient and potentially family and wrote a note, you’re probably in for 30 mins.

Essentially, it’s every minute spent related to patient care (excluding supermarket billable procedures or teaching) when a patient is critically ill.

It does have to be your time, not your residents.

 

[RoyBasch]

Intensivist here - just remember that your critical care time is all encompassing. If you have a patient with a critical illness, you basically can’t spend less than 30 minutes doing it. It includes time spent doing the your H&P, putting in orders, talking to consultants, talking to family, documenting, etc. yes, a STEMI May only be in your ED for 15 minutes, but if you took the prehospital call, called IC, put in orders, read the EKG, talked to the patient and potentially family and wrote a note, you’re probably in for 30 mins.

Essentially, it’s every minute spent related to patient care (excluding supermarket billable procedures or teaching) when a patient is critically ill.

It does have to be your time, not your residents.

Agree completely.

 

[gamerEMdoc]

I'd be careful documenting things like the smoking cessation. If you are actually doing that on all your patients, good for you. But I highly doubt there is many ED docs spending 3 min on smoking cessation on COPD patients, let alone every single smoker. Charting and billing something you didn't do is fraud. And I think frauding medicare is a federal crime? Much like saying you did a complete ROS of systems on every single patient including ankle sprains, if this is showing up on every chart its clearly fraudulant. And there is a ton of focus on balanced billing and patients posting their bill breakdowns online. Wait until someone finds out they are billed for a smoking cessation session when they were in the ED for an ankle sprain and complains about you to their insurance or medicare? Is 0.3 RVUs really worth it?

Just document what you actually do. Don't lie in the chart and make cases out to be something they aren't. Know what cases pay well, and which ones don't. You may think look at the chart rack and see a chest pain, and abd pain, a lac, and a dental pain and think hey, the chest pain or abd pain are the way to go. But the lac and dental pain may be much less time intensive and bill highly because procedures pay. Seeing the dental pain billed at a 99203 and doing a nerve block will net you just as many RVUs as seeing the chest pain or abd pain if you bill those cases at a 99205. But the dental pain can be seen, blocked, and dispositioned in 5-10 minutes. The chest pain and abd pain could linger on your list for hours. Fast track patients where there is a procedure involved are gold mines for RVUs for this reason, they are fast, require little cognitive load, don't stick on your list and bog you down, and pay well. In the last few hours of your shift, when you are winding down and don't want to be picking up cases you can't get dispo'd anyways, its easy just to stop seeing people. But that's the time to get aggressive and seek out these faster dispo patients to pad your numbers.

 

[southerndoc]

My smoking cessation speech: "You should stop smoking." Never have documented that I spent any amount of time on it other than the patient was counseled to stop smoking. Like someone mentioned, it's hard to say I spent 3+ minutes doing it when I didn't spend 5 minutes total in the room.

I don't bill for critical care for appendicitis, cholecystitis, pyelonephritis, etc. unless they have unstable vital signs. I bill for dehydration with BP's <90, HR's >110, etc. I don't feel like I could explain to an auditor how I spent 35 minutes on an appendicitis case even counting the documentation, consultations with surgery, etc.

 

[MechEDoc]

Smoking cessation counseling 3-10m and >10m bills for 0.3 and 0.7 RVU respectively

I kind of take exception with billing for smoking cessation. If you're in a busy department where there is always another patient to see, then even the minimum counseling will be a money losing activity (RVUs earned vs time RVUs earned seeing the next patient). That being said, I can't imagine many ED patients being willing to tolerate 3 minutes (or 10 minutes!) of talking about smoking? It seems like billing for RVUs is either billing fraud or a waste of resources.

 

[deleted836128]

PA here and I also get a productivity bonus. Per hour I typically get around a half to two thirds my hourly rate just in RVUs alone which is more than some of the other PAs. There are some good tips here but here are some of the things I try to follow:

1) As previous posters mention, don’t forget about critical care. I ask myself 1) is there one or more organ systems affected and 2) Is the patient is going to suffer life threatening deterioration if I don’t do something now? Appendicitis often meets this requirement! Even if the patient goes home there are cases when you could still bill for it (like an acute asthma exacerbation you gave three nebulizer treatments, steroids, and magnesium to).

2) Write down that YOU interpreted the tests (doesn’t count if your scribe just imports the computer reading into the chart). I usually put my interpretation and then say “I, Jane Doe PA-C, personally interpreted the EKG.” Same thing with x-rays.

3) Obvious but make sure you measure your lacerations. I don’t know what the exact cut off is but RVUs go up based on laceration length. If it’s really 2.6 cm but you round down to 2.5 cm you could be bumping your compensation down depending on where that cut off is. Also make sure to document if the wound was contaminated, if debridement was necessary or if multiple layers were done because those all increase complexity.

4) If you can bill a higher level make sure your documentation supports it! Can’t tell you how many times I’ve seen charts that could have been billed at an 84 or 85 and they can’t be because the provider didn’t include enough points in the HPI, ROS, or past history. Usually the HPI is the culprit. It needs four elements for an 85 and believe it or not some people aren’t getting this. Just get in a habit of - when did it start, what does it feel like, what makes it better or worse, what treatments have you tried - done! I always ask all these questions on my patients so I get in a habit. You need TEN ROS points to get 85. So easy to knock a few out of the way in one breath - “Have you had fevers, problems breathing, pain, vomiting, or changes in pooping and peeing? Dizziness, numbness or tingling?” You can get a lot of them that way. I also click “no substance abuse” in the psychiatric ROS section because I always ask them about their substance use. Do not forget to ask the patient about surgeries, alcohol and tobacco use, or family history. You need to ask about two of those to bill an 85. Again I always see people missing these! And remember if you import info that’s already there like past diagnoses you have to acknowledge that YOU reviewed it. In my EMR (Cerner) there’s a button for “reviewed in chart.”

5) Record everything you do that increases complexity. If you got the history from EMS, document that. If you called a specialist, make sure it’s documented. If you called the radiologist to talk about the CT - put “discussed with radiologist” when describing the report. If you spent time reviewing old records, document that! I always say something like “I personally reviewed prior records and noted that...”

6) Nursemaids elbows and shoulder dislocation reductions are worth ridiculous RVUs! I hear a patellar dislocation is worth a lot as well but sadly every time I have seen one except for one time it reduced itself. The one time I had a patellar dislocation I tried to reduce it and failed... 20 plus years of experience attending MD failed... Ortho came in and initially failed... but that’s another story.

7) Apply your own splints. EVEN A FINGER SPLINT COUNTS AS A HALF RVU (LOL).

 

[Jabbed]

Placing your own splint includes non-custom splints such as aircasts, knee braces ('Zimmer splints'), etc. Not just orthoglass/plaster custom splints. Document as a splint procedure note and as McNinja mentioned document post splinting neurovascular extremity exam. Easy money.

Also I am told, any critical care time LESS than 33 minutes does not count, so any and all critical care should be at least 33 minutes (no point in documenting 15, 20, 25 mins, etc. of CC time). This has been debated before on this forum, but the definition of acceptable billable CC is probably broader than most people think (any NSTEMI, more than 2L of fluid resuscitation, etc.) Check this forum for broader discussions. Bottom line, a lot of possibly billable CC time isn't captured by ER physician charts.

Something often overlooked is that billing <30 minutes CC time still gives you an automatic level 5 chart even if not met by other criteria. Ie, you don't need a full ROS, physical exam, social/family hx to bill a level 5 chart for a STEMI that spends 15 minutes in the department.

 

[gamerEMdoc]

Something often overlooked is that billing <30 minutes CC time still gives you an automatic level 5 chart even if not met by other criteria. Ie, you don't need a full ROS, physical exam, social/family hx to bill a level 5 chart for a STEMI that spends 15 minutes in the department.

Ive never heard that before. Do you have a source for this?

Aliem’s coding tip sheet would seem to disagree, though that’s hardly a definitive source. They say:

“However, if the documentation of a critical care case does not meet CMS standards, or if the total critical care time is less than 30 minutes, the chart will be billed according to E/M codes. If there is any concern that the chart will not meet critical care criteria, providers should also document according to the appropriate E/M coding coding guidelines.”

If you have a good source for this Id definitely be interested in reading more. This would be a nice loophole, but Ive read a good bit about coding in the past and Ive never come upon this tip before.

 

[Jabbed]

Ive never heard that before. Do you have a source for this?

Aliem’s coding tip sheet would seem to disagree, though that’s hardly a definitive source. They say:

“However, if the documentation of a critical care case does not meet CMS standards, or if the total critical care time is less than 30 minutes, the chart will be billed according to E/M codes. If there is any concern that the chart will not meet critical care criteria, providers should also document according to the appropriate E/M coding coding guidelines.”

If you have a good source for this Id definitely be interested in reading more. This would be a nice loophole, but Ive read a good bit about coding in the past and Ive never come upon this tip before.

As it was explained to me, the description of a 99285 code requires "three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status". Per our coders, CC time is essentially justification of one of these 'constraints'.

 

[Arcan57]

My understanding is that <30 min of CC used to be an automatic level 5 but the rules changed. I know Team (TX/OK decision) wasn’t billing them automatically as Level 5s after the change, YMMV.

 

[Apollyon]

My smoking cessation speech: "You should stop smoking." Never have documented that I spent any amount of time on it other than the patient was counseled to stop smoking. Like someone mentioned, it's hard to say I spent 3+ minutes doing it when I didn't spend 5 minutes total in the room.

Yeah, I was going to post that, but you got to it before me. I tell patients that they should stop smoking, "but I would have to talk about it for 3 minutes, and I'm not going to do that". I do put in the diagnosis "#1 abrasion, R arm #2 tobacco use disorder", though.

 

[gamerEMdoc]

As it was explained to me, the description of a 99285 code requires "three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status". Per our coders, CC time is essentially justification of one of these 'constraints'.

Ok, I get what you are saying. There is a caveat for level 5 that if the patient is critically ill, you can say "patient was too ill to obtain a full history"; "ros limited secondary to the patients critical state", etc. So for instance, you don't need a full ROS on someone who can't talk to you because they are intubated. So in that sense, the coders are saying that if you are claiming its critical care, then they are assuming if your other documentation is shortened, its because the patient is sick. I think that's what they are saying.

I'm not sure that's explicitly spelled out in the E+M codes that way though. My guess is, that's open to a lot of interpretation.

 

[GeneralVeers]

Where is the 33 minute thing for critical care? I have always thought it is any number > than 30 minutes. I just have my scribes randomly generate a number between 31-39 minutes when they do the chart.

 

[thegenius]

I don’t know. 99291 is 30-74 minutes of CC time. Randomly pick a number between those.

 

[BoardingDoc]

Where is the 33 minute thing for critical care? I have always thought it is any number > than 30 minutes. I just have my scribes randomly generate a number between 31-39 minutes when they do the chart.

It isn't a thing. No idea what @RoyBasch is on about. 30 minutes or more qualifies.

 

[BoardingDoc]

1) Appendicitis or anything going emergently to the OR definitely counts. Remember, any condition where "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." counts. Don't overthink it. It's a surgical emergency, hence why they are going "emergently" to the operating room. If there wasn't worry for clinically significant OR life threatening deterioration, they wouldn't be going straight to surgery.

2) If you're going to call it clinical sepsis, then it qualifies. If you're going to call it acute pyelonephritis, then I wouldn't document CC time. All my dx for "sepsis" get CC time.

3) Organ failure counts. Renal failure is a commonly overlooked opportunity to bill CC time. I would recommend diagnosing "acute renal failure", not "renal insufficiency or AKI" if you plan on billing CC for this one.

I think national average is 8%, many in our shop bill for only 4-6% but think about it... We all work in emergency medicine. We deal with emergencies every shift. We really should be billing for more than 4-6% for "critical care" within our field. That's my opinion at least.

I don't buy the appendicitis thing. Almost every appy I send "emergently" to the OR is simply because there is an opening in the OR schedule. The vast majority of these people would be fine sitting on the floor for a day waiting for their surgery. If you're only applying it to patients who are decompensating with abnormal vitals or signs of severe infection, sure. Otherwise, this sounds like a stretch.

Agree about sepsis.

I don't see how a prerenal AKI with a Cr of 4 qualifies. They just need IV fluids. That patient is unlikely to have a "sudden, clinically significant or life threatening deterioration in the patient's condition" if you wait several hours before giving them fluids assuming they're otherwise stable.

 

[Groove]

I don't buy the appendicitis thing. Almost every appy I send "emergently" to the OR is simply because there is an opening in the OR schedule. The vast majority of these people would be fine sitting on the floor for a day waiting for their surgery. If you're only applying it to patients who are decompensating with abnormal vitals or signs of severe infection, sure. Otherwise, this sounds like a stretch.

Agree about sepsis.

I don't see how a prerenal AKI with a Cr of 4 qualifies. They just need IV fluids. That patient is unlikely to have a "sudden, clinically significant or life threatening deterioration in the patient's condition" if you wait several hours before giving them fluids assuming they're otherwise stable.

The reason they often go to surgery post haste is because of the well documented risk of delayed appendectomy leading to perforation which increases morbidity and complications. (i.e. intraabdominal abscess, postoperative fistulas, etc..) OR time usually isn't an issue. Some hospitals have dedicated OR for emergent cases, almost all others have at least one OR available and on-call staff who are scheduled for unexpected surgeries.

Our surgeons will sometimes sit on them until morning (also evidence based (under 6 or 12h) and some take them right away. If they go right away, I call that emergent and I have no problem billing CC because they made a decision that the pt wasn't safe to wait until later or morning. Why wouldn't that qualify? That's a potentially life saving intervention on your part. You resuscitated them, identified a potentially life threatening diagnosis and facilitated timely definitive surgery for their condition.

As for the ARF. That's ARF by RIFLE classification. It's over 3 times baseline. Organ failure is organ failure. I didn't write the rules. Plus, why wouldn't that qualify as a potentially clinically significant OR life threatening deterioration? Most of the times these people have a bump in their K and/or an acidosis. You don't know if they are going to improve or not (even though most do...). They could code halfway through the night. This is from ACEP's website: "

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.

I totally get that you are being conservative with the definition and with your documentation, but I feel that many times we are desensitized to the emergent nature of our cases because we see them so often. If a PCP diagnosed an appy on a pt that he/she was able to squeeze into an imaging center that afternoon and called him with results telling him to go straight to ER... Most of those guys would be skipping and dancing talking about the pt they "saved". An emergency physician on the other hand? Meh....another appy, yawn... Another renal failure...yawn. Another stroke....yawn. Another alcohol withdrawal...yawn.(also qualifies in my book). I'm just a little more liberal with my definition and feel we under document CC.

I guarantee even if I got audited and anyone made an issue of it, I could mount an excellent defense of my charting and it would amount to nothing more than me either updating the chart with an appropriate addendum and/or dropping the charge. Hell, the guidelines are anything but crystal clear. They can't possibly expect everyone to code these at 100%.

 

[Groove]

Here's another one..

Let's take the HTN Urgency that comes in with a headache and BP 240/120. They quit their clonidine 7 days ago. You work them up and give 10-20mg IV hydralazine, clonidine 0.2mg PO and CT them to make sure they don't have a bleed. 2 hours later their BP is 180/90, the HA is gone, they are neurologically afocal, labs are ok, the clonidine and other anti-hypertensives are re-prescribed and you are planning on discharging them home. I would argue that you can bill CC for that. It's a hypertensive "crisis" with potentially life threatening hypertension. You intervened, stabilized them and discharged them. What's the difference between that patient and the one that comes in as a "code stroke" with the same BP, declining GCS, gets tubed and you know before they even hit the scanner that they have a basal ganglia ICH. The only difference is that one of your patients got lucky and the other one didn't. The first one could easily become the second one if you hadn't intervened and appropriately managed their BP.

However, think about how many "HTN Urgency" pts we send home every day. Most of us don't even think about billing CC for these cases.

 

[GeneralVeers]

Here's another one..

Let's take the HTN Urgency that comes in with a headache and BP 240/120. They quit their clonidine 7 days ago. You work them up and give 10-20mg IV hydralazine, clonidine 0.2mg PO and CT them to make sure they don't have a bleed. 2 hours later their BP is 180/90, the HA is gone, they are neurologically afocal, labs are ok, the clonidine and other anti-hypertensives are re-prescribed and you are planning on discharging them home. I would argue that you can bill CC for that. It's a hypertensive "crisis" with potentially life threatening hypertension. You intervened, stabilized them and discharged them. What's the difference between that patient and the one that comes in as a "code stroke" with the same BP, declining GCS, gets tubed and you know before they even hit the scanner that they have a basal ganglia ICH. The only difference is that one of your patients got lucky and the other one didn't. The first one could easily become the second one if you hadn't intervened and appropriately managed their BP.

However, think about how many "HTN Urgency" pts we send home every day. Most of us don't even think about billing CC for these cases.

Actually I'd give them nothing for their BP. That's against ACEP guidelines. I'd probably just treat their HA, and discharge once pain free regardless of BP. Certainly not critical care.

 

[MechEDoc]

Actually I'd give them nothing for their BP. That's against ACEP guidelines. I'd probably just treat their HA, and discharge once pain free regardless of BP. Certainly not critical care.

Same. Headaches aren't encephalopathies.

 

[Groove]

I hear ya, but I don't routinely send out 270/130, 250/120 (pick a number for an egregiously elevated "hypertensive urgency") in my neck of the woods. My pt population are supermorbid obese diabetics replete with HTN emergencies. It's a never-ending stream of HTN induced MIs, strokes, ICH, renal failure, etc.. If I routinely sent out my urgency patients with their ridiculous BPs, I'd find myself with a bad outcome and a lawsuit in no time. The guidelines are purposefully vague with any safe extreme numerical ranges and focus on "symptomatic" with organ failure or "asymptomatic". There's conflicting US and European data. Nobody is going to tell you it's safe to send out ridiculous BPs like that. Tell you what, call up your cardiologist one day when you plan on sending out a 260/130 and see what he says. None of them are going to support that decision. They would all throw you under the bus. These are the same people that hospitalists get frustrated with because they want to keep dischargeable patients in the hospital for 3 days of BP control, lol.

Bad example though. Let's discuss HTN in another thread.

 

[southerndoc]

If you're audited and the charge doesn't carry, it's not just as simple as "dropping the charge." You could be held accountable and criminally charged with fraud. CMS has been arresting physicians for years for fraudulent billing. While I've not read any news stories about critical care billing, CMS considers fraud to be fraud and physicians have been sued and arrested for upcoding charts before. Critical care billing could be viewed as a form of upcoding.

The hypertensive urgency patient who received parenteral agents to lower their blood pressure, the atrial fibrillation at a rate of 160 who received parenteral agents to lower their heart rate, the anaphylaxis who received epinephrine, the renal failure with acidosis or hyperkalemia, the severe dehydration with significant tachycardia or hypotension, etc. are all good examples of appropriate critical care billing. The appendicitis with normal vital signs is stretching it, and you could be viewed as being fraudulent with your billing practices.

 

[gamerEMdoc]

CMs defines CCT as time spent treating 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.”

Appendicitis does not meet this definition. There is no high probability of death if you dont emergently get them to the OR. Its treated with PO antibiotics in some countries.

Things I consider CCT on:

1. Electrical stuff getting drips or getting shocked
2. MI
3. Strokes or PEs you give tpa to
4. Anyone getting tubed, pressors, lines, in other words, most patients Im sending to the ICU
6. Hyperkalemia you are giving a bunch of meds to
7. DKA and other significant causes of acidosis
8. Anyone getting emergent release O- blood
9. Respiratory distress getting bipap and multiple meds
10. Anaphylaxis

Not all encompassing by any means, but thats just off the top of my head some things that trigger CCT billing.

 

[thegenius]

Actually I'd give them nothing for their BP. That's against ACEP guidelines. I'd probably just treat their HA, and discharge once pain free regardless of BP. Certainly not critical care.

ACEP guidelines is for asymptomatic elevated BP. His theoretical case is the elevated BP is causing the HA.

 

[thegenius]

I hear ya, but I don't routinely send out 270/130, 250/120 (pick a number for an egregiously elevated "hypertensive urgency") in my neck of the woods. My pt population are supermorbid obese diabetics replete with HTN emergencies. It's a never-ending stream of HTN induced MIs, strokes, ICH, renal failure, etc.. If I routinely sent out my urgency patients with their ridiculous BPs, I'd find myself with a bad outcome and a lawsuit in no time. The guidelines are purposefully vague with any safe extreme numerical ranges and focus on "symptomatic" with organ failure or "asymptomatic". There's conflicting US and European data. Nobody is going to tell you it's safe to send out ridiculous BPs like that. Tell you what, call up your cardiologist one day when you plan on sending out a 260/130 and see what he says. None of them are going to support that decision. They would all throw you under the bus. These are the same people that hospitalists get frustrated with because they want to keep dischargeable patients in the hospital for 3 days of BP control, lol.

Bad example though. Let's discuss HTN in another thread.

Nah it was a good example Groove. 240/120 I would probably do what you. Problem is HTN emergencies look like emergencies. I think it depends how they look. If they are on their cellphone and in no distress at all, and happy, and came in because their spouse told them to come in...it doesn't matter how high their BP is. It's not an emergency.

It all depends on how you chart. If you chart "they are in distress from their headache, make poor eye contact, keep their eyes closed" when in fact they are not doing that, it bolsters your chance of being able to successful bill, and defend, your decision to do CC time.

Plus you still have to spend > 30 minutes of time with them to bill CC time.