Critical Care time?

[RangerBob]

Any inpatient docs billing for critical care time during rapid responses (or other times of critical workup, like acute neuro change and ordering stat CTs, etc)?

I've typically just bumped up my code to a 99233 for times like that (and add prolonged service if relevant), but a number of internists have said you can bill critical care outside the ICU and many have billed for critical care time responding to rapids on our rehab unit.

I am curious to know what others are doing

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[DMBandFan86]

No I haven’t. If they are getting that sick and deteriorating that fast they should go to another doc. From what I understand you are billing for the time your critical treatments and care took. It just doesn’t make sense to me why you’d be treating a deteriorating patient on rehab as a physiatrist (ie we are not the highest level of preparedness for critical care).

Clinical condition criterion – There is a high probability of sudden, clinically significant, or life-threatening deterioration in the patient's condition which requires the highest level of physician preparedness to intervene urgently.

Treatment criterion – Critical care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or 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.

 

[RangerBob]

No I haven’t. If they are getting that sick and deteriorating that fast they should go to another doc. From what I understand you are billing for the time your critical treatments and care took. It just doesn’t make sense to me why you’d be treating a deteriorating patient on rehab as a physiatrist (ie we are not the highest level of preparedness for critical care).

Clinical condition criterion – There is a high probability of sudden, clinically significant, or life-threatening deterioration in the patient's condition which requires the highest level of physician preparedness to intervene urgently.

Treatment criterion – Critical care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or 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.

Makes sense to me (I assume those are copied from CMS or other guidelines?).

While I do this to some degree (acutely declining patients who need to transfer out stat), probably the bulk of of the "frequent, personal assessment and manipulation by the physician" work is done by the internist while I'm coordinating the transfer/talking with the neurosurgeon (it's always a rebleed vs new bleed after tumor resection and always from an OSH...).

I'd argue we can often meet the criteria for clinical condition. Any patient that needs to transfer out meets that part of the equation.

Treatment condition seems to be the higher burden to meet. Though I think a physiatrist without a hospitalist (which is not my case as we have them) could argue they meet treatment criteria if the pt is de-compensating/needs to transfer to the ICU and they're starting IV abx/IVF/etc. (Assuming that without the IVF they'd crump rather quickly).

It seems to me after reading your post that billing by complexity/time makes more sense for the physiatrist. And likely means less risk for audit.

Is that what everyone else is doing when they have rapid responses/deteriorating patients who transfer? Just code high complexity/prolonged service (if applicable)?

 

[lejeunesage]

Any inpatient docs billing for critical care time during rapid responses (or other times of critical workup, like acute neuro change and ordering stat CTs, etc)?

I've typically just bumped up my code to a 99233 for times like that (and add prolonged service if relevant), but a number of internists have said you can bill critical care outside the ICU and many have billed for critical care time responding to rapids on our rehab unit.

I am curious to know what others are doing

Depends on how much medical management I've done before consulting. And depends on whether I'm discharging them.

So, if a patient has developed something potentially critical (say atrial fib with RVR or PE without hemodynamic instability or RV strain) but not requiring transfer on that very day, I'll keep them and bill 99233.
If they deteriorate next day and I need to transfer them, I bill 99239.