Does moderate risk chest pain get critical care billing? A case example and question

[theWUbear]

I'm a new grad and I'm doing my onboarding training for my new group - reading about critical care documentation.

Two important points I'm picking up:

• There is no official list of what is critical care and what is not, it's interpretation of a rule that cites "impairment of one or more systems & high probability of imminent or life-threatening deterioration"
• Patients that present with a critical appearing presentation (e.g., in distress, abnormal vital signs) and are later determined to not have a life threatening critical care diagnosis may have critical care documented for the critical care delivered for the perceived critical nature of the patient's original presentation

A case: a 58 year old hypertensive diabetic hyperlipidemic smoker with three cardiac stents presents in mild to moderate painful distress with a complaint of chest pain, clutching chest, mildly diaphoretic, states pain is like when he had his last MI. You research old records, you throw in your cardiac workup, you do your charting, your reassessments, maybe a couple sublingual nitros go in (no drip).

Troponin negative, ECG unchanged. HEART score 5. admit for 'chest pain with moderate risk of cardiac etiology', next.

Are you billing for 32 minutes of critical care time for this patient due to the perceived critical nature of his initial presentation for which you considered NSTEMI/STEMI? What features of moderate risk chest pain make you more or less likely to bill for critical care?

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[Fox800]

I would not bill CC for the patient you described. NSTEMI yes I would. Basic CP admission, no way.

I'd buy that if you were on a nitro or heparin drip, or if you were on the phone pushing cardiology to take the patient to the cath lab (but not a STEMI), etc.

 

[e30ftw]

No I would never bill CC on that patient as described.
However I could easily send a htn/dm pt w diaphoresis and hx CAD to the cath lab on heparin for UA/ACS, in which case I would bill CC.
You probably could get reimbursed for CC if you chart the hell out of it but it just doesn’t feel like CC to me and I would feel bad sending the pt the bill.

 

[deleted206819]

I'm a new grad and I'm doing my onboarding training for my new group - reading about critical care documentation.

Two important points I'm picking up:

• There is no official list of what is critical care and what is not, it's interpretation of a rule that cites "impairment of one or more systems & high probability of imminent or life-threatening deterioration"
• Patients that present with a critical appearing presentation (e.g., in distress, abnormal vital signs) and are later determined to not have a life threatening critical care diagnosis may have critical care documented for the critical care delivered for the perceived critical nature of the patient's original presentation

A case: a 58 year old hypertensive diabetic hyperlipidemic smoker with three cardiac stents presents in mild to moderate painful distress with a complaint of chest pain, clutching chest, mildly diaphoretic, states pain is like when he had his last MI. You research old records, you throw in your cardiac workup, you do your charting, your reassessments, maybe a couple sublingual nitros go in (no drip).

Troponin negative, ECG unchanged. HEART score 5. admit for 'chest pain with moderate risk of cardiac etiology', next.

Are you billing for 32 minutes of critical care time for this patient due to the perceived critical nature of his initial presentation for which you considered NSTEMI/STEMI? What features of moderate risk chest pain make you more or less likely to bill for critical care?

Peruse this and put it on your phone and/or print it out and laminate it next to your workstation.

 

[Jabbed]

"Is a chest pain/rule out ACS admit critical care?"

No.

I hope that you're not billing CC time every time you order a CTA because your differential includes aortic dissection..

 

[docB]

I would not bill critical care on that. There are several reasons why not but the most important is that I usually spend less than 10 minutes on a patient like that. Eval, order work up, do other stuff, get work up back, call IM and admit. And IM won't fight on that one. Those are basically my easiest patients.

On a tangent, has anyone else been asked to change the way they document CC from "30 to 70 minutes" to a specific figure like "48 minutes"? We were told we now have to specify the minutes and can't give a range. I don't know if this is just silliness from my billing company or some CMS thing.

 

[Rekt]

Is this an uncommon presentation for your place? I see these like 2-4 times a shift. Couldn't imagine even considering CCT on them. Also, this is a good reason on why it's important for programs to teach the business side of EM, but most don't.

 

[thegenius]

I would not bill critical care on that. There are several reasons why not but the most important is that I usually spend less than 10 minutes on a patient like that. Eval, order work up, do other stuff, get work up back, call IM and admit. And IM won't fight on that one. Those are basically my easiest patients.

On a tangent, has anyone else been asked to change the way they document CC from "30 to 70 minutes" to a specific figure like "48 minutes"? We were told we now have to specify the minutes and can't give a range. I don't know if this is just silliness from my billing company or some CMS thing.

I have never put a range. Instead I have always put a number in like 38, 42, 56, etc. doesn’t matter what you put as long as it’s between 35-70.

Edit: typo should be 30 not 35

 

[BoardingDoc]

I have never put a range. Instead I have always put a number in like 38, 42, 56, etc. doesn’t matter what you put as long as it’s between 35-70.

It's 30-74 minutes for the first block of cc time. Not 35-70.

I also put a specific amount of time. Frequently just 30 min.

 

[thegenius]

I agree I would not charge CC for this guy because chest pain that has normal vitals, normal or unchanged EKG, doesn’t medically require thoracic imaging for a dissection or PE, and has normal labs is unlikely to be critically ill.

Could be ill in 30 mins or 2 hours, but hard to justify dedicating 30+ mins solely on this encounter.

Now, you can still make good money off this patient. Here are some ways:
1) charge CC for 5-10 mins. Say the nurse calls you to the room because “doc he’s having chest pain and he’s diaphoretic, with a history of prior stents.” Clearly even without looking at the EKG, you know he’s high risk. So you could justify charging 5-10 mins of CC time as you get the H&P, review the EKG and do a quick chart review.

Note you don’t make more money if CC time is < 30 mins, but the chart get coded as 99285, which is about 4.9 RVUs.

2) get multiple EKGs. Each one is 0.28 RVUs if I recall. You could certainly justify getting two over a span of 15 mins to see if there are any changes.

4.9 + 0.28 + 0.28 = 5.46 RVUs.
At $35/RVU that is $191.

Corresponding CPT codes:
99284 -> 99285 due to < 30 mins CC time
93010 x2

 

[thegenius]

I believe a patient with that history admitted to the hospital for non-ACS chest pain meeting all of the other required documentation components would likely be a 99285 code and not a 99284 code anyways regardless of not putting <30 minutes CC time.

Perhaps!

Occasionally I actually take the time to actually look up what the billing and coding dept assign my charts and I’m surprised sometimes I’m not getting a 99285 for a patient. Maybe it’s the way i write charts. I don’t know.

 

[Jabbed]

Billing CC time on a chart automatically bumps you to 99285 (so swear my coders). Ie, you do not need to meet the normal 4 point HPI, 2 point PMHX/SHx, 10 point ROS, or 8 point physical exam. If you are not routinely billing for 99285 on level 5 charts you're likely missing one of the above, adequate MDM, or under-billing ICD codes.

 

[Arcan57]

Billing crit care time of >30 minutes bumps you, less than 30 still has you on the hook for the normal elements. Also, you can't (or at least shouldn't) bill crit care time for diseases that end up not being critical. Worried the guy with a severe HA has a SAH but CT's negative and you don't need IV push BP meds (no HTN emergency), then no crit care. Same would apply for normal mental status moderately hyperglycemic pts you think are going to be DKA but aren't. Same thing with the trauma activation that ends up not having any real injuries. Almost every presentation includes something on the differential that would meet the definition of crit care, and sometimes we spend loads of time moving a patient through the system but if they don't actually have a critical diagnosis you're committing fraud.

 

[Arcan57]

Would love to get a definitive answer on whether billing <30 minutes CC time automatically bumps you to a level 5 even if you don’t have all of the other elements of a level 5 chart. My coders have told me that I still need all of the elements. I’ve heard conflicting statements from different people.

We are also required to put a specific number of minutes of CC time performed. I’ve never liked this method of billing as it is almost impossible to accurately do. None of us carries a stopwatch around. It’s just an arbitrary number I feel like we try to guess and put down.

Billing <30 min used to get you a level 5 chart even with missing elements. The criteria for the codes were updated and CC <30 min no longer is an automatic level 5. Attesting to crit care <30 minutes is a meaningless statement in 2020.

 

[deleted109597]

Our system lets us break it down into discrete blocks (consultation, bedside care, other). I almost always randomly put numbers in there that add up to something between 30-39 minutes.
I'm not necessarily worried about an audit, but if one happened there wouldn't really be a pattern of "every case is 31 minutes) or the like.

 

[RustedFox]

Our system lets us break it down into discrete blocks (consultation, bedside care, other). I almost always randomly put numbers in there that add up to something between 30-39 minutes.
I'm not necessarily worried about an audit, but if one happened there wouldn't really be a pattern of "every case is 31 minutes) or the like.

Furthermore, who cares if every case WAS 31 minutes?
We're doing critical care, here.
The last thing we're interested in is counting minutes on a clock.

Hey; insurers - shut up and pay up.
Oh, its too expensive?! Really?
Fire the 8 administrators for every doc out there.
That'll free up some money.

 

[deleted109597]

Furthermore, who cares if every case WAS 31 minutes?
We're doing critical care, here.
The last thing we're interested in is counting minutes on a clock.

I mean, we shouldn't be. But it's 2020. We are beholden to it. I can get an email that both applauds the percentage of critical care time and at the same time asks if I should be seeing more patients per hour.
I mean, I cannot bill 80 minutes of critical care every hour. And I cannot see patients while performing critical care. But here we are.

Hey; insurers - shut up and pay up.
Oh, its too expensive?! Really?
Fire the 8 administrators for every doc out there.
That'll free up some money.

They actually aren't mad at us getting the money. It's the fact that if I bill a 99291, the hospital gets 10x more for that care too. Even though they a) didn't do any of it and b)often actively worked against me during it.

 

[turkeyjerky]

Lol, what a jacked up system.

Quick Q—I always thought part of the time in critical care could be for “being available”, is this not true?

 

[Siggy]

I wonder if one of the considerations of the coders is if there's a hand off and the next ED provider wants to add a 99292. A vague "30-75 minutes" makes it hard to justify a 99292. Obviously this is a bigger issue on the inpatient side than most ED critical care coding.

 

[deleted109597]

Lol, what a jacked up system.

Quick Q—I always thought part of the time in critical care could be for “being available”, is this not true?

No. Otherwise I could bill 12 hours of critical care time for every patient in the department.

 

[The Knife & Gun Club]

I would not bill CC for the patient you described. NSTEMI yes I would. Basic CP admission, no way.

I'd buy that if you were on a nitro or heparin drip, or if you were on the phone pushing cardiology to take the patient to the cath lab (but not a STEMI), etc.

Wait wait wait - NSTEMI is critical care?

I just had my first real baby-deer-in-headlights shift as an intern. First guy was a tachycardic CHF’r with what turned out to be an NSTEMI. Did some nitro, lovenox, ASA, admit to medicine. Seemed non-critical enough at the time.

I can log that in my procedure log at CC time?

 

[Fox800]

Wait wait wait - NSTEMI is critical care?

I just had my first real baby-deer-in-headlights shift as an intern. First guy was a tachycardic CHF’r with what turned out to be an NSTEMI. Did some nitro, lovenox, ASA, admit to medicine. Seemed non-critical enough at the time.

I can log that in my procedure log at CC time?

Probably. Was there an organ system at risk that you stabilized? Generally, if I admit patients on heparin drips I bill CC. Especially if you stabilized unstable vital signs. Lovenox SQ is kind of a grey area but I bet you could sell it. Cardiology consult? Supplemental oxygen? Diuresis?

 

[thegenius]

What was the lovenox for? Was it CHF with afib?

a true NSTEMI is critical care, especially if there are diffuse EKG changes and active chest pain. Regardless of vital signs. Only makes it easier once the trop comes back 1.5.

you would be surprised what CC is billable. Remember it really has little to nothing to do with whether you think they are critical, it’s more of a billing diagnosis than a medical diagnosis. That’s why asthma attacks that require (or get) continuous albuterol is critical care, which on it’s face seems silly. Because every time you give a continuous neb, that can be considered critical care. Which is why some people always log it as such.

 

[The Knife & Gun Club]

Probably. Was there an organ system at risk that you stabilized? Generally, if I admit patients on heparin drips I bill CC. Especially if you stabilized unstable vital signs. Lovenox SQ is kind of a grey area but I bet you could sell it. Cardiology consult? Supplemental oxygen? Diuresis?

Thanks so much for the info! Literally would never have known any of that if not for SDN. Did all that stuff, so I guess it’d count.

What was the lovenox for? Was it CHF with afib?

a true NSTEMI is critical care, especially if there are diffuse EKG changes and active chest pain. Regardless of vital signs. Only makes it easier once the trop comes back 1.5.

Some trial showed subQ lovenox was superior to Unfractionated heparin in NSTEMI. And it’s way quicker for our overworked county nurses to administer. At least that’s what my attending said. I’m still just a glorified Med student really.

 

[docB]

Wait wait wait - NSTEMI is critical care?

I just had my first real baby-deer-in-headlights shift as an intern. First guy was a tachycardic CHF’r with what turned out to be an NSTEMI. Did some nitro, lovenox, ASA, admit to medicine. Seemed non-critical enough at the time.

I can log that in my procedure log at CC time?

Hang on. Critical care time for billing and critical care time for your residency may be different things. Talk to your program director and see what they want you to put in your procedure log. The discussion here has been about attending billing for cases that take longer than 30 minutes and meet certain criteria. CMS decided that doctors should be able to bill for extra money in these cases. Often, as you've noticed from reading the thread, what we think of as a complicated critical patient and a case that merits critical care billing may not be the same thing.

As a for example I'll throw out a controversial case that will likely start some debate. Some STEMIs may not meet critical care billing criteria as many are in and out of the department in under 30 minutes. I can be argued that you can bill critical care if you spend over 30 minuets on the case including documentation and consultant calls even though the patient wasn't in your care for 30 minutes but you have to be really good on your documentation.

 

[BoardingDoc]

As a for example I'll throw out a controversial case that will likely start some debate. Some STEMIs may not meet critical care billing criteria as many are in and out of the department in under 30 minutes. I can be argued that you can bill critical care if you spend over 30 minuets on the case including documentation and consultant calls even though the patient wasn't in your care for 30 minutes but you have to be really good on your documentation.

Not sure what the debate would be here. STEMI absolutely meets criteria for cc time. You only get paid if you can document 30+ minutes spent on the patient. If you're at a tertiary care center with a cath lab and the patient spends literally 5 minutes in the ED before going to cath, it's pretty hard to justify 30 minutes of care on that patient, even if you count documentation.

That said, outside of that very specific scenario, it's pretty easy to justify 30 mins if you include time spend looking at the EKG, charting, ordering heparin/whatever, arranging transport (if needed), calling cardiology, talking to the patient etc etc.

 

[thegenius]

As a for example I'll throw out a controversial case that will likely start some debate. Some STEMIs may not meet critical care billing criteria as many are in and out of the department in under 30 minutes. I can be argued that you can bill critical care if you spend over 30 minuets on the case including documentation and consultant calls even though the patient wasn't in your care for 30 minutes but you have to be really good on your documentation.

That is not controversial, I know what you mean. You can have a STEMI that is in and out of the ED in 8 minutes, and it's actually quite hard to bill > 30 minutes even if you include time calling consultant(s), chart documentation, and even talking to family.

Sometimes though, they end up being right about 31 minutes in length.

 

[RoyBasch]

I'm a new grad and I'm doing my onboarding training for my new group - reading about critical care documentation.

Two important points I'm picking up:

• There is no official list of what is critical care and what is not, it's interpretation of a rule that cites "impairment of one or more systems & high probability of imminent or life-threatening deterioration"
• Patients that present with a critical appearing presentation (e.g., in distress, abnormal vital signs) and are later determined to not have a life threatening critical care diagnosis may have critical care documented for the critical care delivered for the perceived critical nature of the patient's original presentation

A case: a 58 year old hypertensive diabetic hyperlipidemic smoker with three cardiac stents presents in mild to moderate painful distress with a complaint of chest pain, clutching chest, mildly diaphoretic, states pain is like when he had his last MI. You research old records, you throw in your cardiac workup, you do your charting, your reassessments, maybe a couple sublingual nitros go in (no drip).

Troponin negative, ECG unchanged. HEART score 5. admit for 'chest pain with moderate risk of cardiac etiology', next.

Are you billing for 32 minutes of critical care time for this patient due to the perceived critical nature of his initial presentation for which you considered NSTEMI/STEMI? What features of moderate risk chest pain make you more or less likely to bill for critical care?

Definitely not critical care. For frame of reference, I am one of the highest billers of CC time in my group. If troponin is elevated and you call it a type 1 NSTEMI, that would be critical care. Although if trop is elevated from demand ischemia or chronically elevated, or delta trop with no rise, I would not call that critical care, unless the underlying process causing demand ischemia also requires a critical treatment (i.e. pulmonary edema requiring vasoactive gtt).

 

[deleted859535]

Definitely not critical care. For frame of reference, I am one of the highest billers of CC time in my group. If troponin is elevated and you call it a type 1 NSTEMI, that would be critical care. Although if trop is elevated from demand ischemia or chronically elevated, or delta trop with no rise, I would not call that critical care, unless the underlying process causing demand ischemia also requires a critical treatment (i.e. pulmonary edema requiring vasoactive gtt).

Exactly true for me. High CCT billing, same billing practice. Calling wimpy bull**** negligible troponin elevation a clinically meaningful type II NSTEMI when that's unlikely to be the case is disingenuous at best (or betrays a lack of understanding of the pathology), fraudulent at worst as it pertains to CCT.

The folks I heparinized with their quintupled troponins and good clinical story are definitely CCT.

(OP, this is all really beyond your purposes since your case logging isn't the same as CCT billing in the real world, and CCT billing doesn't apply to residents, but it's useful information nonetheless.)