Critical care encounters

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Jabbed

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Does anyone have data on the frequency of critical care coding nationally/regionally? What percentage of my charts should bill out as critical care time?

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Nationally, it is about 8.1% based on the “CMS – 2016 Medicare Utilization Data by Specialty” as seen on epmonthly.com
 
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Does anyone have data on the frequency of critical care coding nationally/regionally? What percentage of my charts should bill out as critical care time?
Busy community ER
Group average is 11%
 
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I think I billed around 11-14% at my last RVU gig (55K community ED). I probably am only around 4-5% at my current gig but that's because we're non RVU and I don't have to stress about all the documentation so I tend to forget to bill for it.
 
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Most EM docs underbill for critical care time
 
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Totally depends on your situation. Busy trauma center with APPs skimming off the low acuity might be 10-15%. I work at a rural critical access hospital that is mostly urgent care stuff and we average 3-4%. Middle of the road community hospital site I work at is right at the national average around 8%.
 
Agree that it is dependent upon your site and acuity level. 7-8% around average, but can be 10%+ at higher acuity EDs.

Everyone always thinks about critical care when trying to increase revenue. Critical care makes up a smaller percentage of total patients seen and overall revenue though.

It’s important to remember that level 4 and 5 encounters are going to make up the majority of your billing.

You can more easily generate increased revenue by moving level 3 to level 4, and level 4 to level 5 encounters by appropriately meeting all of the billing elements that you might be forgetting to include.
 
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I was asked by my cmg to increase billing for CC. One example they gave was of a patient who literally never got a room in the ED and I spoke to for < 90 seconds in a corner of a hallway because the waiting room was under construction …. Because he got a blood transfusion (once he got upstairs)

I flatly refused and they left me alone after that. Granted I’m a nocturnist so I rarely see anyone “important”

Then they went bankrupt …. Whoops 🤣

I realize there are things we *can* bill CC for but there’s no way I could stretch it to >30 minutes spent on the case.. a few years ago I got a bill for an ER visit and I reported it, because the midlevel that saw me hadn’t spent 5 minutes with me, there’s no way on earth they spent 30 minutes on my care, and the attending didn’t see me at all. Gtfo.
 
I was asked by my cmg to increase billing for CC. One example they gave was of a patient who literally never got a room in the ED and I spoke to for < 90 seconds in a corner of a hallway because the waiting room was under construction …. Because he got a blood transfusion (once he got upstairs)

I flatly refused and they left me alone after that. Granted I’m a nocturnist so I rarely see anyone “important”

Then they went bankrupt …. Whoops 🤣

I realize there are things we *can* bill CC for but there’s no way I could stretch it to >30 minutes spent on the case.. a few years ago I got a bill for an ER visit and I reported it, because the midlevel that saw me hadn’t spent 5 minutes with me, there’s no way on earth they spent 30 minutes on my care, and the attending didn’t see me at all. Gtfo.
I hear what you are saying. And thanks for helping bankrupt a CMG 😉

If you were in a fairer SDG or at least productivity based model though you’d be incentivized to be paid for that patient, which also gets the patient better care in my opinion. You’d have discussed with staff, pulled the patient into a room, transfused them in the ED, and made more money while expediting care for the patient in a better environment.

The amount of critical care time is mostly arbitrary. Any time you have a critical care diagnosis, you can easily justify 30+ minutes with evaluating a patient, reevaluating a patient, interpreting cardiac monitor, pulse oximetry and other diagnostic testing, consulting for admission, and documentation of care.

Everyone usually does and should spend 30 minutes on a critically ill patient. We just often think that we don’t. If you see on average 2 pph then you are spending 30 minutes on every patient. The vast majority aren’t critically ill. If you can’t justify 30 minutes on a critically ill patient. How can you justify spending 30 minutes on anyone else?

The minutes are arbitrary. The crime is paying us by the minute. We are physicians, professionals, not time clock punchers.
 
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I hear what you are saying. And thanks for helping bankrupt a CMG 😉

If you were in a fairer SDG or at least productivity based model though you’d be incentivized to be paid for that patient, which also gets the patient better care in my opinion. You’d have discussed with staff, pulled the patient into a room, transfused them in the ED, and made more money while expediting care for the patient in a better environment.

The amount of critical care time is mostly arbitrary. Any time you have a critical care diagnosis, you can easily justify 30+ minutes with evaluating a patient, reevaluating a patient, interpreting cardiac monitor, pulse oximetry and other diagnostic testing, consulting for admission, and documentation of care.

Everyone usually does and should spend 30 minutes on a critically ill patient. We just often think that we don’t. If you see on average 2 pph then you are spending 30 minutes on every patient. The vast majority aren’t critically ill. If you can’t justify 30 minutes on a critically ill patient. How can you justify spending 30 minutes on anyone else?

The minutes are arbitrary. The crime is paying us by the minute. We are physicians, professionals, not time clock punchers.
No question there are patients that require that level of care and I provide it when needed. But someone who has a hgb of 6.9 when it was 7.4 last week and their pcp sent them in for a transfusion is not that.
And I agree we shouldn’t be paid by minutes but that is unchanged with the new billing requirements, right? So I’m not going to say I spent 30 minutes on something I spent 5 minutes on. Afib is another example … some people with afrvr need multiple meds, discussion with cardiology etc but many I put in the cardizem, a while later admit to the hospitalist, off they go, that did not take 30 minutes. My point is that many people who have a potentially CC diagnosis are not critically sick.

I think it’s more important to maximize level 5 charts. Many people who aren’t critical take up more time for various reasons, and there may be more nuance to their care - somewhat sick appearing abdominal pain and medium risk chest pain come to mind. JMTC
 
No question there are patients that require that level of care and I provide it when needed. But someone who has a hgb of 6.9 when it was 7.4 last week and their pcp sent them in for a transfusion is not that.
And I agree we shouldn’t be paid by minutes but that is unchanged with the new billing requirements, right? So I’m not going to say I spent 30 minutes on something I spent 5 minutes on. Afib is another example … some people with afrvr need multiple meds, discussion with cardiology etc but many I put in the cardizem, a while later admit to the hospitalist, off they go, that did not take 30 minutes. My point is that many people who have a potentially CC diagnosis are not critically sick.

I think it’s more important to maximize level 5 charts. Many people who aren’t critical take up more time for various reasons, and there may be more nuance to their care - somewhat sick appearing abdominal pain and medium risk chest pain come to mind. JMTC
Your prerogative. That's easy lost revenue though. You can bill critical care on any blood transfusion. The circumstances aren't incredibly relevant to billing. You only spent 5 minutes on the entire patient encounter (evaluating, reevaluating, interpreting cardiac telemetry/pulse oximetry and documenting)? I suspect you spent longer. You deserve to be paid for your time.

EPs underestimate what is critical care appropriate billing because some things no longer seem that critical to us. Anemia and hypoglycemia are classic examples.

I agree with your point that it's important to maximize level 5 charts. I'd also do the same for level 4 charts. These charts will make up most of your overall billing.

Time, billing and risk don't always correlate. Trauma takes up way more time than a STEMI, but can end up billing the same. Popping in a hip pays way more for the risk involved than does an intubation.
 
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