critical care level 5 chart

[Pudortu]

Curious if anyone here knows the answer as I can't get a straight answer out of everyone.

If I found a patient was mildly hypoxic (such as covid with O2 88% on RA) and gave them NC oxygen and documented critical care of 5-10 min, does that lead to a level 5 chart? I realize I cannot get the big RVU money maker with >30 min Critical Care time, but was hoping to at least bump the chart to a level 5. Thanks all.

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[bravotwozero]

Yeah I’d bill that as a level 5 all day long.

 

[wareagle726]

For that chart no need to bill the CC to make a level 5 chart. Hypoxia requiring O2(at least acutely) is going to require a workup, expanded exam, possibly admission, etc..

 

[Arcan57]

So what I think you're asking is does billing <30min of CC automatically make the chart billed as a Level 5?

The answer to that is an unequivocal no. My understanding is at some point in the past this was true, but hasn't been true for a while. If you want a level 5 chart, you still have to hit the HPI, PE, ROS, and SocHx along with your MDM points to justify the charge. Critical care of >30 minutes requires the attestation but the rest of your chart matter from a billing perspective.

 

[southerndoc]

@Arcan57 is right. It used to automatically "upcode" your chart to a 5 if you only documented to a 2, 3, or 4. However, now you must document to a 5. If you bill for <30 mins critical care, you have to document as if you didn't even put a critical care note in there.

However, having said that, I think it's good to document critical care <30 mins for the sole reason if you're ever audited, you can show that you don't bill 40 mins critical care for every patient. An SVT that quickly converts? 10 mins. The auditors could see that and it probably would help you defend yourself that you're actually spending the amount of time you are claiming with critical care.

 

[Fox800]

Do you get paid for CC if you provide less than 30 minutes of CC?

Or does it by default get billed as a level 5?
I bill CC/write CC attestations MUCH more than my colleagues, probably because we are hospital employed and I've worked at private groups in the past.

 

[Janders]

While it is certainly fine to write <30min of CC time (and I do, occasionally… STEMI out the door in 20 minutes, code called 5 minutes after arrival)…

I would caution writing 10 minutes, because you surely spent MORE than 10 minutes! Its not JUST time at bedside. Its timing taking a history, including any history from EMS / family. Performing an exam. Writing orders. Reading old data in the computer (last d/c summary, whatever). Reviewing and interpreting each of the labs when they return. Re-evaluating the patient when you get labs back, ensuring your intervention is improving them. Speaking with the patient and family. Speaking with the admitting hospitalist. And Charting all of that. Oh and also any bundled procedures count too (interpretation of pulse ox, interpretation of chest X-ray, phlebotomy, peripheral IV placement, NG Tube).

So if you told me you did all of that in 22 minutes, I would believe it. If you told me it took 35 minutes, I would believe that. Saying you really only spent a grand total of 10 minutes on all aspects of the care of a hypoxic respiratory failure coming into the hospital with COVID is certainly possible, but… are you admitting 6 of these an hour for multiple hours in a row on shift? I thought not.

Don’t exaggerate, but don’t short change yourself.

(And yes, certainly some of my COVID patients who “only” get decadron and nasal oxygen I have written for CC time)

 

[southerndoc]

While it is certainly fine to write <30min of CC time (and I do, occasionally… STEMI out the door in 20 minutes, code called 5 minutes after arrival)…

I would caution writing 10 minutes, because you surely spent MORE than 10 minutes! Its not JUST time at bedside. Its timing taking a history, including any history from EMS / family. Performing an exam. Writing orders. Reading old data in the computer (last d/c summary, whatever). Reviewing and interpreting each of the labs when they return. Re-evaluating the patient when you get labs back, ensuring your intervention is improving them. Speaking with the patient and family. Speaking with the admitting hospitalist. And Charting all of that. Oh and also any bundled procedures count too (interpretation of pulse ox, interpretation of chest X-ray, phlebotomy, peripheral IV placement, NG Tube).

So if you told me you did all of that in 22 minutes, I would believe it. If you told me it took 35 minutes, I would believe that. Saying you really only spent a grand total of 10 minutes on all aspects of the care of a hypoxic respiratory failure coming into the hospital with COVID is certainly possible, but… are you admitting 6 of these an hour for multiple hours in a row on shift? I thought not.

Don’t exaggerate, but don’t short change yourself.

(And yes, certainly some of my COVID patients who “only” get decadron and nasal oxygen I have written for CC time)

I was only using 10 mins as an example because it was first to come to mind.

 

[Pudortu]

Thanks all for clarifying. I appreciate your help!

 

[Janders]

I was only using 10 mins as an example because it was first to come to mind.

I was really responding to OP who was suggesting documenting 5-10min CC.

I can’t see and discharge a routine flu shot in a healthy patient in 5 minutes

 

[Mount Asclepius]

I think it’s fairly easy to demonstrate >30 minutes of cc time with any critically ill patient.

Has anyone ever been audited and found wrong for billing >30 minutes cc time?

 

[gamerEMdoc]

Curious if anyone here knows the answer as I can't get a straight answer out of everyone.

If I found a patient was mildly hypoxic (such as covid with O2 88% on RA) and gave them NC oxygen and documented critical care of 5-10 min, does that lead to a level 5 chart? I realize I cannot get the big RVU money maker with >30 min Critical Care time, but was hoping to at least bump the chart to a level 5. Thanks all.

No. In order to bill for a 99291 you need to get over 30 min. Any chart less than 30 would be billed at the appropriate EM code (level 1-5) so in order to bill for a 99215, you would need to reach all the documentation milestones for that. Now, if the patient is too sick to be able to get a full history, or exam, etc, you can state that and still reach level 5.

I'd argue that putting a patient on supplemental O2 (unless its bipap) alone isn't critical care. But in cases where critical care is performed, its relatively easy to get to 30 min.

 

[Jabbed]

Minor hijack, how often are people billing >75 minutes of critical care time. I see some of my partners billing 120 minutes on some cases, which seems like a red flag.

 

[lucid_leprechaun]

Minor hijack, how often are people billing >75 minutes of critical care time. I see some of my partners billing 120 minutes on some cases, which seems like a red flag.

I’ve certainly billed that high. But usually for peri arrest patients that I’ve intubated/resuscitated who stay in the department for 4 hrs getting labs/imaging while I do frequent rechecks and have discussions with multiple consultants.

 

[Janders]

Minor hijack, how often are people billing >75 minutes of critical care time. I see some of my partners billing 120 minutes on some cases, which seems like a red flag.

Every stayed a couple hours after shift, calling and presenting a patient to a dozen different tertiary ICUs, trying to find an accepting physician? Those are the cases where I put initially silly appearing times… though I also document the laundry list of effort involved getting the patient to definitive care.

 

[thegenius]

I'd argue that putting a patient on supplemental O2 (unless its bipap) alone isn't critical care. But in cases where critical care is performed, its relatively easy to get to 30 min.

Agree...unless their O2 is 80% or less. But that generally means they are quite sick for whatever reason and might need 30 ml / kg, immediate antibiotics, maybe pressors, etc.

We have docs who claim CC for anyone < 90%. Crazy

 

[thegenius]

Every stayed a couple hours after shift, calling and presenting a patient to a dozen different tertiary ICUs, trying to find an accepting physician? Those are the cases where I put initially silly appearing times… though I also document the laundry list of effort involved getting the patient to definitive c

I'll do 80 - 100 if I spend a sihit ton of time with the patient. It's rare though. I do it maybe 1/month

 

[Mount Asclepius]

When are people billing critical care for hypoxia? I general do if <80% on RA or baseline supplemental oxygen. I see EPs that transfer patients to our facility billing critical care for any oxygen saturation of 80-90% requiring supplemental oxygenation regardless if respiratory distress present or not. Do you base upon a defined number, presence of respiratory distress, general overall picture, or some other criteria related to hypoxia?

 

[Dr Mantis Toboggan]

When are people billing critical care for hypoxia? I general do if <80% on RA or baseline supplemental oxygen. I see EPs that transfer patients to our facility billing critical care for any oxygen saturation of 80-90% requiring supplemental oxygenation regardless if respiratory distress present or not. Do you base upon a defined number, presence of respiratory distress, general overall picture, or some other criteria related to hypoxia?

The whole critical care charge deal is kind of BS. Pay us a fair rate based on the diagnosis. I don’t need 35 min to manage severe DKA etc, someone slower who needs to look everything up shouldn’t get more money than me in this scenario.

 

[dadaddadaBATMAN]

Minor hijack, how often are people billing >75 minutes of critical care time. I see some of my partners billing 120 minutes on some cases, which seems like a red flag.

Periarrest or active arrest multiple times or calling like 4 consultants after above or just whole system clogged requiring me to baby sit endlessly on bs Cc stuff

 

[Brigade4Radiant]

Minor hijack, how often are people billing >75 minutes of critical care time. I see some of my partners billing 120 minutes on some cases, which seems like a red flag.

I do that a lot of the time looking at records reassessment and admission. Most docs under bill for critical care also. Also It’s percentages not time. I only bill critical care time for about 6% of my patients.

The patient is under your care until you admit them if I consult reassess look at labs that is an hour or two hours.

I talk to our coders all the time if you are document your consults reassessment it’s often an hour or more.

Look at ICU notes for your admitted patients they bill for 60-90 minutes when we do the initial workup.

Also things like a brain bleed or giving blood are always critical care.

 

[thegenius]

Also things like a brain bleed or giving blood are always critical care.

Interesting you say giving blood...because I used to think that but the fact is most of the blood we give isn't emergent.

Giving blood for the Hg drop from 10 to 7.4 over 5 months is not CC.

Giving blood because the Hg transiently varies from 8.0 to 6.8 ALL THE TIME, and the PMD happened to pick up 7.2 and sent patient to the ER, is not CC.

 

[Brigade4Radiant]

Interesting you say giving blood...because I used to think that but the fact is most of the blood we give isn't emergent.

Giving blood for the Hg drop from 10 to 7.4 over 5 months is not CC.

Giving blood because the Hg transiently varies from 8.0 to 6.8 ALL THE TIME, and the PMD happened to pick up 7.2 and sent patient to the ER, is not CC.

Its meddata critical care criteria if you give blood it counts as critical care. Same as a subdural that neurosurgery just watches.

I also don’t give blood for a drop from 10 to 7.4. If you chronically need to be given blood it’s still critical care like the chronic dka

Also most care that EM docs do isn’t emergent at all. Most work ups are negative so if we go by that logic most chest pains should be a level 3

 

[lucid_leprechaun]

Its meddata critical care criteria if you give blood it counts as critical care. Same as a subdural that neurosurgery just watches.

I also don’t give blood for a drop from 10 to 7.4. If you chronically need to be given blood it’s still critical care like the chronic dka

Also most care that EM docs do isn’t emergent at all. Most work ups are negative so if we go by that logic most chest pains should be a level 3

Yeah a lot of the diagnoses included as critical care are things we don’t think about as truly critical. I think it’s a bad name. Take a look at a list of eligible diagnoses online and the majority of it is things we see every day and don’t worry that much about.

ED Charting and Coding: Critical Care Time

ED Charting and Coding: Critical Care Time - Are you appropriately coding your Emergency Department charts for your critical care patients?

www.aliem.com

 

[Brigade4Radiant]

Yeah a lot of the diagnoses included as critical care are things we don’t think about as truly critical. I think it’s a bad name. Take a look at a list of eligible diagnoses online and the majority of it is things we see every day and don’t worry that much about.

ED Charting and Coding: Critical Care Time

ED Charting and Coding: Critical Care Time - Are you appropriately coding your Emergency Department charts for your critical care patients?

www.aliem.com

Yes that’s true which is why EM docs under bill a lot. People think that sometimes a doc is overcoming but they are using CMS definitions.

 

[BoardingDoc]

Minor hijack, how often are people billing >75 minutes of critical care time. I see some of my partners billing 120 minutes on some cases, which seems like a red flag.

I do 80-100 min probably once or twice a month. Generally it's due to me spending hours trying to transfer them and then having to constantly go back and tinker with drips or whatnot.

 

[Janders]

Go back to the definition:
“Critical illness or injury = illness or injury that impairs one or more "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= direct medical care for the patient that involves “high complexity decision making to assess, manipulate, and support vital organ system failure.”
CMS additionally mandates that 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".

There is obviously a fair amount of grey, but MOST ED providers UNDERBILL critical care, partially by underestimating how long patient care takes but more so because we are so USED to critical illness that the more minor critical stuff that doesn’t involve RSI and a vent doesn’t phase us the way it should.

So if someone has COVID, is hypoxic, has respiratory distress… what is their death rate? High, yeah? Did you actively intervene, with oxygen and IV decadron? Did you reassess them? Did you get a couple dozen labs, and imaging studies, and an EKG and used your years of knowledge to assess these and further modify your treatment plans? Did you admit them and speak with them, their family, and their new hospitalist?

Don’t short change yourself, you do a LOT of critical care and don’t break a sweat.

 

[wareagle726]

Go back to the definition:
“Critical illness or injury = illness or injury that impairs one or more "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= direct medical care for the patient that involves “high complexity decision making to assess, manipulate, and support vital organ system failure.”
CMS additionally mandates that 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".

There is obviously a fair amount of grey, but MOST ED providers UNDERBILL critical care, partially by underestimating how long patient care takes but more so because we are so USED to critical illness that the more minor critical stuff that doesn’t involve RSI and a vent doesn’t phase us the way it should.

So if someone has COVID, is hypoxic, has respiratory distress… what is their death rate? High, yeah? Did you actively intervene, with oxygen and IV decadron? Did you reassess them? Did you get a couple dozen labs, and imaging studies, and an EKG and used your years of knowledge to assess these and further modify your treatment plans? Did you admit them and speak with them, their family, and their new hospitalist?

Don’t short change yourself, you do a LOT of critical care and don’t break a sweat.

this. 100%. we are trained at such a high level of acuity that we downplay so many CC patients.

 

[Jabbed]

Go back to the definition:
“Critical illness or injury = illness or injury that impairs one or more "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= direct medical care for the patient that involves “high complexity decision making to assess, manipulate, and support vital organ system failure.”
CMS additionally mandates that 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".

There is obviously a fair amount of grey, but MOST ED providers UNDERBILL critical care, partially by underestimating how long patient care takes but more so because we are so USED to critical illness that the more minor critical stuff that doesn’t involve RSI and a vent doesn’t phase us the way it should.

So if someone has COVID, is hypoxic, has respiratory distress… what is their death rate? High, yeah? Did you actively intervene, with oxygen and IV decadron? Did you reassess them? Did you get a couple dozen labs, and imaging studies, and an EKG and used your years of knowledge to assess these and further modify your treatment plans? Did you admit them and speak with them, their family, and their new hospitalist?

Don’t short change yourself, you do a LOT of critical care and don’t break a sweat.

Yes, but 2 L NC and the equivalent of 40 mg of prednisone just seems difficult to justify as 'aggressive lifesaving intervention'.

What is the death rate for elderly person presenting with abdominal pain? High. But it would be ludicrous to bill for CC for the elderly belly pain who gets morphine, fluids, CT and goes home.

I adhere pretty closely to the CC time guidelines that med data puts out. They do list specific vital signs that constitute critical care. Ie, hypoxia <80% on usual oxygen requirements = critical care. SBP > 230 mmHg with intervention = critical care. HR > 150 with intervention = critical care. Honestly, I have no idea what this is based on but it definitely improves my documentation as my CC billing is littered with buzz words and phrases and never gets down-coded. I am fairly aggressive (>15%) and I bill virtually all of my CC time from 30-40 minutes.

 

[Fox800]

We way under-bill for critical care. Someone told me "if it makes an FM doc crap their pants and send the patient to the ER or call an ambulance, there's a pretty good chance it's critical care".

 

[Fox800]

You can even provide critical care and discharge a patient home. Giving adenosine for SVT? Critical care.

 

[southerndoc]

You can even provide critical care and discharge a patient home. Giving adenosine for SVT? Critical care.

Most SVT's convert with adenosine. Are you telling me that you've spent 30+ minutes while the patient is critical? If you spent 5-10 minutes with them while critical, they convert and stabilize, and then you've spent 20+ minutes documenting things?

I agree SVT is critical care, but it's converted so quickly that I find a hard time finding 30+ minutes of critical care time with them unless you sit at the beside for 29 minutes and on minute 30 decide to push adenosine.

 

[Brigade4Radiant]

Most SVT's convert with adenosine. Are you telling me that you've spent 30+ minutes while the patient is critical? If you spent 5-10 minutes with them while critical, they convert and stabilize, and then you've spent 20+ minutes documenting things?

I agree SVT is critical care, but it's converted so quickly that I find a hard time finding 30+ minutes of critical care time with them unless you sit at the beside for 29 minutes and on minute 30 decide to push adenosine.

Reevaluating and getting a second EKG on the monitor and reinterpreting a rhythm strip reassessment and discharge instructions. Just because you convert the SVT doesn’t mean that the patient may still go back into the rhythm do you mediately takeoff pads and discharge them as soon as they convert? Then I would agree with you.

Plus cardiology consultation for followup.

 

[southerndoc]

Reevaluating and getting a second EKG on the monitor and reinterpreting a rhythm strip reassessment and discharge instructions. Just because you convert the SVT doesn’t mean that the patient may still go back into the rhythm do you mediately takeoff pads and discharge them as soon as they convert? Then I would agree with you.

Plus cardiology consultation for followup.

My point is the patient is not critical during the repeat EKG, discussing with cardiology, observing, etc.

Sure, they could go back into it, but an appendicitis could become septic easily. If the appendicitis has a BP of 90 when they arrive and are dehydrated, do you bill for critical care?

I don't put pads on my SVT patients unless I need to cardiovert them. Nor do I speak to cardiology before discharging them unless it's persistent SVT or has an elevated troponin.

 

[Brigade4Radiant]

My point is the patient is not critical during the repeat EKG, discussing with cardiology, observing, etc.

Sure, they could go back into it, but an appendicitis could become septic easily. If the appendicitis has a BP of 90 when they arrive and are dehydrated, do you bill for critical care?

I don't put pads on my SVT patients unless I need to cardiovert them. Nor do I speak to cardiology before discharging them unless it's persistent SVT or has an elevated troponin.

That’s fine most of that critical care things are just cms things. Like a 12 point review of systems on most of the time they aren’t even warranted

 

[larpleston]

My point is the patient is not critical during the repeat EKG, discussing with cardiology, observing, etc.

Sure, they could go back into it, but an appendicitis could become septic easily. If the appendicitis has a BP of 90 when they arrive and are dehydrated, do you bill for critical care?

I don't put pads on my SVT patients unless I need to cardiovert them. Nor do I speak to cardiology before discharging them unless it's persistent SVT or has an elevated troponin.

Don't think it works like this. If someone comes in with SVT and you give them adenosine, all of your time spent with that patient after they 'stabilize' is spent on their initial diagnosis, SVT, which bills critical care - they don't have to be in extremis for every minute you bill. Never heard of anyone dividing up a single patient encounter into both critical and non critical portions, when the diagnosis clearly merits CC time.

 

[southerndoc]

Don't think it works like this. If someone comes in with SVT and you give them adenosine, all of your time spent with that patient after they 'stabilize' is spent on their initial diagnosis, SVT, which bills critical care - they don't have to be in extremis for every minute you bill. Never heard of anyone dividing up a single patient encounter into both critical and non critical portions, when the diagnosis clearly merits CC time.

It will not withstand an audit. You can cheat on your taxes every year, and if you're not caught, well it doesn't make it acceptable.

See CMS Pub 100-04, transmittal 2997, change request 8688 (2014-07-25) which offers this example for an attending attesting to a resident note (p 13):

Acceptable Example of Documentation: "Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident's documentation and I agree with the resident's assessment and plan of care."

CMS billing, SEP-1, and EMTALA are things I routinely professionally consult on in a variety of fashions.

 

[larpleston]

It will not withstand an audit. You can cheat on your taxes every year, and if you're not caught, well it doesn't make it acceptable.

See CMS Pub 100-04, transmittal 2997, change request 8688 (2014-07-25) which offers this example for an attending attesting to a resident note (p 13):

Acceptable Example of Documentation: "Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident's documentation and I agree with the resident's assessment and plan of care."

CMS billing, SEP-1, and EMTALA are things I routinely professionally consult on in a variety of fashions.

I pulled up the document. This is specifically under "Teaching Physician Criteria" and they are making the point that you can't bill for time that a resident spent on patient care that you weren't directly involved in. Nowhere in that document does it state that time spent on a critically ill patient doesn't count once you stabilize them, within the same encounter. If you know of someone who has been audited for billing more than 30 minutes of CC time on an anaphylaxis or SVT patient I'd want to know the details though. Not really trying to debate, just have never heard of anyone divvying up their CC time vs non CC time this way on the same patient in the same encounter, never heard it brought up in our talks with coders, and cannot find anything to state that it should be done.

 

[southerndoc]

I pulled up the document. This is specifically under "Teaching Physician Criteria" and they are making the point that you can't bill for time that a resident spent on patient care that you weren't directly involved in. Nowhere in that document does it state that time spent on a critically ill patient doesn't count once you stabilize them, within the same encounter. If you know of someone who has been audited for billing more than 30 minutes of CC time on an anaphylaxis or SVT patient I'd want to know the details though. Not really trying to debate, just have never heard of anyone divvying up their CC time vs non CC time this way on the same patient in the same encounter, never heard it brought up in our talks with coders, and cannot find anything to state that it should be done.

I can't discuss details, but if a RAC gets your critical care charts, we may be meeting in person for some one-on-one time.

 

[Brigade4Radiant]

I can't discuss details, but if a RAC gets your critical care charts, we may be meeting in person for some one-on-one time.

Most EM physician's underbill and RAC typically goes after hospitals or companies such as Envision, Apollo, Team Health. We also have coders and this is what they tell we have meetings on this.

 

[Mount Asclepius]

Time spent documenting also counts towards critical care. You don’t have to finish documenting while the patient is still in the ED. Therefore, it makes sense to me that the patient doesn’t have to technically be critically ill for every second of your critical care time. However, more often than not, critical illness doesn’t resolve within 30 minutes.

I bill critical care every time on a STEMI even if they are only briefly in the ED as I feel you can easily justify 30 minutes of time talking to EMS, talking to and examining the patient, interpreting the EKG(s), pulse oximetry, labs and CXR, ordering meds, consulting Cardiology, a quick reevaluation prior to cath and then documentation. I don’t think CMS is coming after people trying to take away critical care billing for someone taking care of a life threatening heart attack. I think they are looking for clearer cases of fraudulent billing. Audits with negative verdicts are also very rare.

PSVT that quickly converts and goes home feels a little different to me though. I usually don’t bill critical care on these patients. They are often young and healthy. They usually aren’t unstable as in hypotensive. They usually quickly convert. I also don’t feel that someone going home likely had a critical condition. On the rare occasion where the initial dysrhythmia is of unclear etiology, prolonged or unstable, then I might consider billing critical care.

I also struggle with acute on chronic or subacute SDHs that I consult Neurosurgery and admit without performing any other intervention. MedData suggests that you can bill critical care for any head bleed. The standard critical care attestation though states that you provided an intervention. Does consultation and admission suffice? I don’t know.

The whole critical care charge deal is kind of BS. Pay us a fair rate based on the diagnosis.

I agree with @DrMantisTobaggan that having to pick an amount of time for critical care billing is ridiculous. Everyone just guesses anyways, putting in variability just in case of the mythical audit.

It’s very similar to how ridiculous it is to do a complete ROS for a level 5 chart. No one worth their salt working in a busy ED with a ~30% admit rate has time to go through each system of a complete ROS with every patient that otherwise meets criteria for a level 5 chart. Plus, some patients try to figure out if all of your questions really matter then, so they answer yes to some things that aren’t really true because they think it will help you. I don’t care about your unrelated second of chest pain 3 days ago. Also, in reality you read the triage note, knew the likely diagnosis, knew they were going to get admitted, and are just dotting the I’s and crossing the T’s so you get paid before moving on to the next patient.

I struggle though with the idea of paying solely based upon diagnosis as most ED visits aren’t emergent and are of low acuity. That doesn’t mean we instantly knew that the chest pain patient wasn’t a STEMI right when they presented to triage.

 

[larpleston]

''

I can't discuss details, but if a RAC gets your critical care charts, we may be meeting in person for some one-on-one time

I'll take my chances. There is far too much ambiguity in the guidelines for either of us to say with certainty that we are correct.

 

[southerndoc]

On another note, I did bill for critical care for SVT today. Took nurses a few minutes to get IV access because of the patient being obese, Vagal maneuvers didn't work, and it took 3 doses of adenosine. That plus documentation time definitely exceeded the 30 minute mark.

 

[Fox800]

It doesn't have to be 30 minutes of critical care time, you just won't get paid for CC if it's under 30 minutes. You can count time at the bedside (5-10 minutes) reevaluation (5 minutes), chart stalking, and documenting. That easily gets you to 20 minutes. More if you are monitoring the patient for a while, giving fluids and reassessing, getting serial EKGs, etc. Who is going to tell you that it doesn't take 10 minutes to write a chart (pended and worked on later) and 2 minutes to review each EKG, over multiple EKGs?

However, CC documentation can justify a level 5 chart. It takes me 10 seconds to dictate a CC note, and thus basically guarantee it won't get downloaded to something stupid (level 4). It also shows I'm good at billing/coding compared to my peers (minor concern).

Most SVT's convert with adenosine. Are you telling me that you've spent 30+ minutes while the patient is critical? If you spent 5-10 minutes with them while critical, they convert and stabilize, and then you've spent 20+ minutes documenting things?

I agree SVT is critical care, but it's converted so quickly that I find a hard time finding 30+ minutes of critical care time with them unless you sit at the beside for 29 minutes and on minute 30 decide to push adenosine.

 

[jw3600]

I bill every Covid patient (being admitted for hypoxia and supplemental O2) as critical care with a diagnosis of "Acute Hypoxic Respiratory Failure."

 

[Mount Asclepius]

I bill every Covid patient (being admitted for hypoxia and supplemental O2) as critical care with a diagnosis of "Acute Hypoxic Respiratory Failure."

Seems a little aggressive to me to do for every hypoxic patient, especially given some are only 87-89% on RA, many just need 1-2 lpm NC and we’re sending a few home without admission in that condition. Not saying you can’t bill critical care in those scenarios, but every hypoxic patient doesn’t always feel like critical care. I also usually bill critical care pretty heavily as I think we often underestimate critical care. Curious what others are doing.

 

[TrailRun]

I was wondering too about Covid for the mild hypoxia, whether that qualifies, because of the theoretical risk of decompensation/intubation, etc. Also, when we built critical care, do the patients actually have to pay more themselves or is it more the insurance that pays?

 

[Apollyon]

Also, when we built critical care, do the patients actually have to pay more themselves or is it more the insurance that pays?

That's a clean question with a messy answer. Just as an example, about 13 years ago I was admitted to the hospital, to a floor bed, for 4 days. The final bill was $14k, but, as I had a BC/BS plan at the time, it was capitated down to about $3k for them to pay the hospital. However, due to my plan, I had to pay 10% of the bill - not the capitated, but, the full bill. So, I had to cut a check for $1400.

So, choose your adjective - one person's "complex" is another's "messy".

 

[thegenius]

That's a clean question with a messy answer. Just as an example, about 13 years ago I was admitted to the hospital, to a floor bed, for 4 days. The final bill was $14k, but, as I had a BC/BS plan at the time, it was capitated down to about $3k for them to pay the hospital. However, due to my plan, I had to pay 10% of the bill - not the capitated, but, the full bill. So, I had to cut a check for $1400.

So, choose your adjective - one person's "complex" is another's "messy".

$1400 for 4 days. That's $350/day. Not the worst cost ever as some hotels charge the same amount. but I'm sure you didn't choose to be in the hospital, and you probably didn't get to choose when to leave, and you certainly weren't gifted peanuts, mini-bar, and a masseuse either.

 

[Apollyon]

$1400 for 4 days. That's $350/day. Not the worst cost ever as some hotels charge the same amount. but I'm sure you didn't choose to be in the hospital, and you probably didn't get to choose when to leave, and you certainly weren't gifted peanuts, mini-bar, and a masseuse either.

I hear ya, but, for me, it was more that, even with insurance, I was paying $1 for every $2 they were.