I like treat and street patients

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Emapp20177 said:
I thought all SDGs were amazing to work for once you hit partner?
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I thought that too. Mine was run like a pyramid scheme. Partners are over non partners yes. But if you want the good life you needed to be a manager or director and all the good spots are taken by people that are going to die in their seat. Some have occupied it nearly since I was born. We were all knights serving undying kings.

I keep waiting to wake up and miss EM and it still hasn't happened.
 
AlmostAnMD said:
I thought that too. Mine was run like a pyramid scheme. Partners are over non partners yes. But if you want the good life you needed to be a manager or director and all the good spots are taken by people that are going to die in their seat. Some have occupied it nearly since I was born. We were all knights serving undying kings.

I keep waiting to wake up and miss EM and it still hasn't happened.
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its important to understand the group structure so you aren't stuck in these BS groups. Honestly it is like USucks talking about how they are "clinician" owned. DBag WAS is a clinician.. now a businessman. The Apollo guys arent clinicians. Etc etc. I think the number of good SDGs is few and likely shrinking.

You have to have a degree of altruism to do it right. Few people and even fewer EM physicians have that. The ones who say they do have no control over these groups. Perhaps it is something with the old generation as my interactions with the younger docs has been more hopeful but who knows.
 
AlmostAnMD said:
I thought that too. Mine was run like a pyramid scheme. Partners are over non partners yes. But if you want the good life you needed to be a manager or director and all the good spots are taken by people that are going to die in their seat. Some have occupied it nearly since I was born. We were all knights serving undying kings.

I keep waiting to wake up and miss EM and it still hasn't happened.
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Wow. Our busier admin people get a set schedule but it's the same shift mix as the rest of us. We elect our leadership and encourage newer partners to step into leadership roles. Sorry your experience wasn't great.
 
AlmostAnMD said:
I thought that too. Mine was run like a pyramid scheme. Partners are over non partners yes. But if you want the good life you needed to be a manager or director and all the good spots are taken by people that are going to die in their seat. Some have occupied it nearly since I was born. We were all knights serving undying kings.

I keep waiting to wake up and miss EM and it still hasn't happened.
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Was this a deal you made in trade for a sweet location?

Unless this was a completely locked down market or there were some other hefty benefits you're leaving out... why?

Out here in the real world where my metro has 4 or 5 hospital systems pretty much all hiring (sure they're all CMGs but c'est la vie), I would just bail for a different job, and so would most of my colleagues I'd reckon.
 
Treating and streeting is satisfying until you see the RVUs at the end of the month. The "test and admit everyone" docs are generally $50-$100/hr higher if you work in an all RVU place.
 
Top productivity based income comes from, in highest to lowest order, sheer hours worked, volume of patients seen, increased testing, maximized charting, and discharge over admit given room turnover, with critical care, observation and procedural billing accurately reflected instead of under billed. Exceptions to this order, but generally true.
 
I think it depends.. i live in a paradigm when all patients are level 4,5, or critical care. Learn the new billing guidelines. I know of multiple groups all around the country who have no 1s or 2s and their level 3s are like 1%.

wRVU for a level 4 ~2.74
wRVU for a level 5 ~4.00
WRVU for CC ~4.5

You can literally order 0 tests and dc a level 4. Level 5s can chew up time. I tend to agree that volume is king and generally I can see a ton of ankle sprains in the amount of time i spend with a 35 yr old ab pain who gets a CT or US.

Admissions can limit flow in your dept and therefore harm volume.

I agree hours matter most then volume, then charting, then ordering stuff. If you chart wisely you dont need to order tests but of course sometimes the patients need testing.

Overall, I agree with Mount above.. slight discrepancy when it comes to charting vs testing but it is close. I think perhaps what matters is the specific testing. If you order CT/US it’s a time and dispo killer.
 
EctopicFetus said:
You can literally order 0 tests and dc a level 4. Level 5s can chew up time. I tend to agree that volume is king and generally I can see a ton of ankle sprains in the amount of time i spend with a 35 yr old ab pain who gets a CT or US.
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Write a prescription will get you a level 4. What in history/risk gets level 4 without testing?

Also, in our MDM, if I prescribe ibuprofen >200 mg I consider that prescription medication. Epic defaults to it being OTC.
 
Discharged atypical chest pains are great for RVUs. Big differential, testing, independent interpretation of EKG. Should be able to get a 99285 and DC in less than 3 hrs.
 
ScepticSkeksis said:
Treating and streeting is satisfying until you see the RVUs at the end of the month. The "test and admit everyone" docs are generally $50-$100/hr higher if you work in an all RVU place.
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Definitely not true. I have the fastest door to discharge time in our group and I admit the lowest % of patients. I am earning as much or more than our "test and admit" cohort by virtue of the volume that I see.

You can argue that if both cohorts see the same number of patients per shift, that yeah, sir tests-a-lot will make more money. But in that scenario the onus lies on the treat-and-street doc to pick up the pace as those patients tend to be shorter encounters.
 
southerndoc said:
Write a prescription will get you a level 4. What in history/risk gets level 4 without testing?

Also, in our MDM, if I prescribe ibuprofen >200 mg I consider that prescription medication. Epic defaults to it being OTC.
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Yeah, I think that getting a 4 with no tests is hard. Ankle sprain with an Rx for Diclofenac gel is my easy lvl 4 chart (xray interpretation and Rx). I think you can get there with an asthma exacerbation.

Column 1: One chronic illness with acute exacerbation (lvl 4)
Column 2: Nothing
Column 3: Rx for prednisone (lvl 4)

Most people who get a 4 in column 1 tend to get tests though.
 
BoardingDoc said:
Yeah, I think that getting a 4 with no tests is hard. Ankle sprain with an Rx for Diclofenac gel is my easy lvl 4 chart (xray interpretation and Rx). I think you can get there with an asthma exacerbation.

Column 1: One chronic illness with acute exacerbation (lvl 4)
Column 2: Nothing
Column 3: Rx for prednisone (lvl 4)

Most people who get a 4 in column 1 tend to get tests though.
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My confidence to not get any tests is very low.

Patients love tests and if they don't get labs for their whatever and CXR for a cough/asthma if often leads to complaints, especially when they go to another ED or urgent scare the following day and get a Z pack for "pneumonia."
 
EctopicFetus said:
I think it depends.. i live in a paradigm when all patients are level 4,5, or critical care. Learn the new billing guidelines. I know of multiple groups all around the country who have no 1s or 2s and their level 3s are like 1%.

wRVU for a level 4 ~2.74
wRVU for a level 5 ~4.00
WRVU for CC ~4.5

You can literally order 0 tests and dc a level 4. Level 5s can chew up time. I tend to agree that volume is king and generally I can see a ton of ankle sprains in the amount of time i spend with a 35 yr old ab pain who gets a CT or US.

Admissions can limit flow in your dept and therefore harm volume.

I agree hours matter most then volume, then charting, then ordering stuff. If you chart wisely you dont need to order tests but of course sometimes the patients need testing.

Overall, I agree with Mount above.. slight discrepancy when it comes to charting vs testing but it is close. I think perhaps what matters is the specific testing. If you order CT/US it’s a time and dispo killer.
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I don’t disagree. I think it also matters what the rate limiting steps are in your department, as well as if a test or admission is going to keep you from seeing another patient versus if there isn’t further volume of patients to see.

Admissions and holding usually bog down a department because of inpatient flow issues. Testing doesn’t always if done efficiently and not strung along. Certain departments have different challenges such as nursing, techs, labs, and imaging with each having the potential to decrease physician efficiency in moving a patient through the department. You also don’t have to do a ton of testing on each patient to meet the billing category requirements. You just need the optimal amount to rule out the emergency, make the patient happy, and optimize financial productivity. Ordering unnecessary big workups with labs, EKG, XR, CT, US and MRI on lots of patients will hurt you.

We all know from medical school that you don’t want to perform tests that aren’t indicated, or that lead to further downstream negative tests possibly including the risk of a procedural/surgical complication that the test led to when the test wasn’t really indicated from the start. However, people want some testing often more than they want a physician’s opinion/expertise. Some people are going to doctor shop until they know exactly which virus is causing their cold. There is also risk of not knowing when they are going to do that as they will likely end up with an unnecessary antibiotic. Either way probably not the end of the world and side tangent that people demanding expensive unnecessary viral PCR panels is contributing to our bloated health care costs. Some people are just going to end up with a cholecystectomy, appendectomy, hysterectomy and ventral hernia repair no matter what testing you do for their eventual chronic abdominal pain. On the other hand Ottawa rules mean nothing. The harm of an extremity x-ray is insignificant and likely won’t impact flow. Patients often want you to validate their opinion that they need a test even if they don’t. You just have to balance that desire with necessity, the flow of your department, and overall patient volume to maximize productivity.

At the end of the day, those that work longer and harder make more. Follows most jobs out there. You can somewhat work smarter, not harder through testing and charting. You are right EctopicFetus, as many miss out on low hanging fruit such as critical care billing, as well as turning 3s to 4s and 4s to 5s. Depending on the environment I’d flip the order of the importance of testing and charting. Many miss the forest for trees though by not realizing it’s just working more hours and seeing more patients that leads to more money.
 
Mount Asclepius said:
I don’t disagree. I think it also matters what the rate limiting steps are in your department, as well as if a test or admission is going to keep you from seeing another patient versus if there isn’t further volume of patients to see.

Admissions and holding usually bog down a department because of inpatient flow issues. Testing doesn’t always if done efficiently and not strung along. Certain departments have different challenges such as nursing, techs, labs, and imaging with each having the potential to decrease physician efficiency in moving a patient through the department. You also don’t have to do a ton of testing on each patient to meet the billing category requirements. You just need the optimal amount to rule out the emergency, make the patient happy, and optimize financial productivity. Ordering unnecessary big workups with labs, EKG, XR, CT, US and MRI on lots of patients will hurt you.

We all know from medical school that you don’t want to perform tests that aren’t indicated, or that lead to further downstream negative tests possibly including the risk of a procedural/surgical complication that the test led to when the test wasn’t really indicated from the start. However, people want some testing often more than they want a physician’s opinion/expertise. Some people are going to doctor shop until they know exactly which virus is causing their cold. There is also risk of not knowing when they are going to do that as they will likely end up with an unnecessary antibiotic. Either way probably not the end of the world and side tangent that people demanding expensive unnecessary viral PCR panels is contributing to our bloated health care costs. Some people are just going to end up with a cholecystectomy, appendectomy, hysterectomy and ventral hernia repair no matter what testing you do for their eventual chronic abdominal pain. On the other hand Ottawa rules mean nothing. The harm of an extremity x-ray is insignificant and likely won’t impact flow. Patients often want you to validate their opinion that they need a test even if they don’t. You just have to balance that desire with necessity, the flow of your department, and overall patient volume to maximize productivity.

At the end of the day, those that work longer and harder make more. Follows most jobs out there. You can somewhat work smarter, not harder through testing and charting. You are right EctopicFetus, as many miss out on low hanging fruit such as critical care billing, as well as turning 3s to 4s and 4s to 5s. Depending on the environment I’d flip the order of the importance of testing and charting. Many miss the forest for trees though by not realizing it’s just working more hours and seeing more patients that leads to more money.
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Our RVU based place is old and sick central. Good luck getting away without a lot of tests and high admission rate. We also order a lot of MRIs to be able to discharge patients, as dumb as that sounds, it's much faster than trying to admit them.
 
TooMuchResearch said:
Our RVU based place is old and sick central. Good luck getting away without a lot of tests and high admission rate. We also order a lot of MRIs to be able to discharge patients, as dumb as that sounds, it's much faster than trying to admit them.
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Also in a similar environment at one of our sites. Important to maximize observation billing to get paid for doing the inpatient work while tying up a room for longer patient LOS.
 
Mount Asclepius said:
Also in a similar environment at one of our sites. Important to maximize observation billing to get paid for doing the inpatient work while tying up a room for longer patient LOS.
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Fair enough. We can still get 90% of these big workup discharges out in 4-6 hours so doubtful trying to bill observation would help but I don't know for sure.
The admits get managed by hospitalists while boarding downstairs.
 
ScepticSkeksis said:
Treating and streeting is satisfying until you see the RVUs at the end of the month. The "test and admit everyone" docs are generally $50-$100/hr higher if you work in an all RVU place.
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Nope. I know our group finances well. Aside from pure hours worked, volume of patients seen is king. IF your shop isn’t busy, and there are ONLY 2pt per hour for your to see, THEN perhaps adding tests / admitting will bump your pay. Thats a lot of caveats. Bigger bang for your buck properly getting your critical care percentage up, and learning the things that bump a level 4 to a level 5 that involve charting, NOT changing how you practice.

Its VERY easy to get to a level 5 on discharge; ergo admission itself doesn’t REALLY bump your pay. Now getting double the CT scans may, but with the current coding rules you could just document why you considered it and didn’t get it…

In our group:
The highest $/hr is the lowest or second lowest admit rate in the group (and ergo lower testing rate in general)
The second and third highest $/hr are the highest admit/transfer rates, who tend to order more CT than #1 above.
Dr. Low Admission is generally tied for highest % critical care with second place Dr. Admits More, despite their large gulf in admission rates!

Comparing amongst the entire group, what actually delineates these people isn’t admit rate, or CT-rate, it is patietn per hour, critical care billing, and ability to push mix towards level 5 and away from level 4….
 
My first job out of residency, the uni hospital had a chest pain unit. The guy who worked there full time (IM, not EM) knew CC billing inside and out, even if he was discharging a pt. He was the highest CC biller, by far. Unfortunately, he went under a car on his motorcycle, and that was the end of him.
 
Emapp20177 said:
In my experience (100% RVU job), this is not true.

Volume is King.
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I work both salary and RVU jobs and I generally agree volume is king. The average chart is like 4.2 RVUs, working them up more might move you to 4.6 or so which good...
..but it's much better to just see 5 more patients.

If all you are worried about is $$$ then just see as many as possible.
Pt's won't like you because you don't actually talk to them, but that's another convo. Or it can be this one.
 
southerndoc said:
Write a prescription will get you a level 4. What in history/risk gets level 4 without testing?

Also, in our MDM, if I prescribe ibuprofen >200 mg I consider that prescription medication. Epic defaults to it being OTC.
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Right...or better yet. Any complaint they come in with (COPA 2-5), look at some prior labs (DATA 4) and write a script (RISK 4).
MDM 4
30 seconds.
can do this for everything but suture removal and dressing changes.
 
thegenius said:
Right...or better yet. Any complaint they come in with (COPA 2-5), look at some prior labs (DATA 4) and write a script (RISK 4).
MDM 4
30 seconds.
can do this for everything but suture removal and dressing changes.
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Yeah, I try to do this with the absolute complete BS complaints like "please refill my HTN meds."

Rx for HCTZ or whatever written (lvl 4), and:
Review of PMP documented
Review of medication fill hx documented
Review of prior labs/outpatient visits (if any in system). If not --> Consideration of tests not performed: blood testing considered but not indicated given lack of systemic symptoms and no concern for hypertensive emergency with end organ damage.
 
Apollyon said:
My first job out of residency, the uni hospital had a chest pain unit. The guy who worked there full time (IM, not EM) knew CC billing inside and out, even if he was discharging a pt. He was the highest CC biller, by far. Unfortunately, he went under a car on his motorcycle, and that was the end of him.
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Very few places are willing to be aggressive about cracking down on inappropriate CC billing. If you're willing to bill 90 min of CC for a d/c'ed UTI in a healthy 28 yo woman, you can average > $100/hr above the group average in an RVU model.
 
Arcan57 said:
Very few places are willing to be aggressive about cracking down on inappropriate CC billing. If you're willing to bill 90 min of CC for a d/c'ed UTI in a healthy 28 yo woman, you can average > $100/hr above the group average in an RVU model.
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This sounds like the ass on reddit who argues that every appy, transfer, or other non CC BS is CC.
 
Brigade4Radiant said:
Oh i would like to see. But a lot of things that you can bill for CC I don't consider critical care
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The issue is purely financially you cant bill more than 2 pph of cc.. you cant bill 12 hours of critical care in a 10 hour shift.. the government will be up your butt.

Similarly it is super not worth billing 99292s.. of course if you spend that much time with a patient you are worth getting paid for it but purely form a $$ perspective it is much better to see another patient.
 
Brigade4Radiant said:
Oh i would like to see. But a lot of things that you can bill for CC I don't consider critical care
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An appy that I would happily dose with abx and discharge with an early AM pre-op time (not that the system is set up to support this) is not CC.

A transfer is not CC just because I have to make phone calls to coordinate care.

An early cholecystitis getting abx and pain control with OR later in the day or next day is not CC.

But according to reddit guy, all are CC. Absolute garbage.
 
Arcan57 said:
Very few places are willing to be aggressive about cracking down on inappropriate CC billing. If you're willing to bill 90 min of CC for a d/c'ed UTI in a healthy 28 yo woman, you can average > $100/hr above the group average in an RVU model.
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Is this bc they usually get away with it and it rarely raises a red flag with CMS?
 
TooMuchResearch said:
An appy that I would happily dose with abx and discharge with an early AM pre-op time (not that the system is set up to support this) is not CC.

A transfer is not CC just because I have to make phone calls to coordinate care.

An early cholecystitis getting abx and pain control with OR later in the day or next day is not CC.

But according to reddit guy, all are CC. Absolute garbage.
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Not sure the exact things being billed but

1) appy or chole meeting sirs criteria (maybe it's just mild fever and leukocytosis) is sepsis and I'm billing cc for that no matter what

2) transfer for stable trauma admissions is getting CC as I am transferring to a higher level of care
 
WhatJobDoIPick said:
1) appy or chole meeting sirs criteria (maybe it's just mild fever and leukocytosis) is sepsis and I'm billing cc for that no matter what
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Incorrect. The definition of sepsis requires organ dysfunction. Majority of appendicitis and cholecystitis patients are not septic. Sepsis is often under billed, but this isn’t the scenario.
 
Mount Asclepius said:
Incorrect. The definition of sepsis requires organ dysfunction. Majority of appendicitis and cholecystitis patients are not septic. Sepsis is often under billed, but this isn’t the scenario.
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Chole with elevated LFTs doesn't count as organ dysfunction?
I'm asking, not arguing.
 
RustedFox said:
Chole with elevated LFTs doesn't count as organ dysfunction?
I'm asking, not arguing.
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Not technically per the CMS definition. Transaminitis doesn’t meet the definition. Bilirubin greater than 2 does. It may be another one of those classic arbitrary whole number cutoffs in medicine that doesn’t necessarily have the best evidentiary support, but it’s what is used for CMS criteria.

I wouldn’t bill critical care on a hypothetical ‘stable’ 40ish year old patient with cholecystitis, a HR of 92, WBC of 13, minimal transaminitis, bilirubin of 2.1 and a lactate of 2.2 that you admit to the med-surg floor overnight with plan for cholecystectomy in the morning. Some might. I don’t think that is the spirit of critical care billing or consistent with a few standard critical care billing guidelines.

For a septic patient with a lactate greater than 4, significant tachycardia with a HR greater than 120, or hypotension with SBP less than 90 or MAP less than 65, then I think very justified. You don’t see those abnormalities though with most cholecystitis. More likely with cholangitis or severe pancreatitis. Occasionally with cholecystitis in patients with advanced age.

I’m just making a clinical point that most patients with cholecystitis aren’t septic. Same goes for appendicitis patients. I’m also making the billing point that I don’t think billing critical care on most cholecystitis patients is justified. There is a good chance you’ll be able to get away with it, but it’s sketchy. I haven’t been through an audit personally, but wouldn’t want to try to defend it. I even say this as someone who is in the higher side of critical care billing in our group and fully believes in maximizing critical care billing.
 
Mount Asclepius said:
Not technically per the CMS definition. Transaminitis doesn’t meet the definition. Bilirubin greater than 2 does. It may be another one of those classic arbitrary whole number cutoffs in medicine that doesn’t necessarily have the best evidentiary support, but it’s what is used for CMS criteria.

I wouldn’t bill critical care on a hypothetical ‘stable’ 40ish year old patient with cholecystitis, a HR of 92, WBC of 13, minimal transaminitis, bilirubin of 2.1 and a lactate of 2.2 that you admit to the med-surg floor overnight with plan for cholecystectomy in the morning. Some might. I don’t think that is the spirit of critical care billing or consistent with a few standard critical care billing guidelines.

For a septic patient with a lactate greater than 4, significant tachycardia with a HR greater than 120, or hypotension with SBP less than 90 or MAP less than 65, then I think very justified. You don’t see those abnormalities though with most cholecystitis. More likely with cholangitis or severe pancreatitis. Occasionally with cholecystitis in patients with advanced age.

I’m just making a clinical point that most patients with cholecystitis aren’t septic. Same goes for appendicitis patients. I’m also making the billing point that I don’t think billing critical care on most cholecystitis patients is justified. There is a good chance you’ll be able to get away with it, but it’s sketchy. I haven’t been through an audit personally, but wouldn’t want to try to defend it. I even say this as someone who is in the higher side of critical care billing in our group and fully believes in maximizing critical care billing.
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Since we are being technical… i dont think it is CMS defining this. I might be wrong but it is the “surviving sepsis” campaign.

Looking specifically into organ dysfunction there is literature that says tbili >1.2 is the organ dysfunction cut off based off SOFA scores.

inflammregen.biomedcentral.com

Organ dysfunction as a new standard for defining sepsis - Inflammation and Regeneration

Despite advances in intensive care and the widespread use of standardized care included in the Surviving Sepsis Campaign Guidelines, sepsis remains a leading cause of death, and the prevalence of sepsis increases concurrent with the aging process. The diagnosis of sepsis was originally based on...
inflammregen.biomedcentral.com inflammregen.biomedcentral.com

SEP-3 also notes that a bill of 1.2 to 1.9 (SOFA) gets you a score of 1.. you need a score of 2 to have a higher risk of death from sepsis.. which a bill of 2 gets you. But you cant get 1 point for a bill of 1.2 and another point from a MAP of under 70, low platelets, creatinine of 1.2 etc..

 
Mount Asclepius said:
Not technically per the CMS definition. Transaminitis doesn’t meet the definition. Bilirubin greater than 2 does. It may be another one of those classic arbitrary whole number cutoffs in medicine that doesn’t necessarily have the best evidentiary support, but it’s what is used for CMS criteria.

I wouldn’t bill critical care on a hypothetical ‘stable’ 40ish year old patient with cholecystitis, a HR of 92, WBC of 13, minimal transaminitis, bilirubin of 2.1 and a lactate of 2.2 that you admit to the med-surg floor overnight with plan for cholecystectomy in the morning. Some might. I don’t think that is the spirit of critical care billing or consistent with a few standard critical care billing guidelines.
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CC is a billing diagnosis and has little to do with what you literally do in the ER. If someone has sepsis, I'll consider it, and if there lactate is > 2 then you know what? THEY ARE SEPTIC. If the govermnet wants to guide and control our every move with septic patients because THEY think they deserve more quick medical attention, then charge CC time. It is. You are watching them closely, mobilizing resources immediately away from other parts of the hospital, and they have a higher likelyhood of decompensation according the government.

They want us to bill CC time for these patients. So do it.

You and I don't care about lactates between 1.8 and 2.2. These are just stupid numbers. but the government cares so bill CC time. They are critical! They are telling you they are critical!
 
thegenius said:
CC is a billing diagnosis and has little to do with what you literally do in the ER. If someone has sepsis, I'll consider it, and if there lactate is > 2 then you know what? THEY ARE SEPTIC. If the govermnet wants to guide and control our every move with septic patients because THEY think they deserve more quick medical attention, then charge CC time. It is. You are watching them closely, mobilizing resources immediately away from other parts of the hospital, and they have a higher likelyhood of decompensation according the government.

They want us to bill CC time for these patients. So do it.

You and I don't care about lactates between 1.8 and 2.2. These are just stupid numbers. but the government cares so bill CC time. They are critical! They are telling you they are critical!
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I am billing CC for anyone that I am admitting for lactic 2 or higher. IDC if it's from sepsis, dehydration, Cyclical vomiting etc. you (proverbial you) can leave RVUs on the table that's fine.

SIRS + source = sepsis

Sepsis + end organ dysfunction (lactic over 2) = severe sepsis

CMS is cutting our pay 3% in 2025 and some people wanna play the "spirit of critical care" game lol.
 
WhatJobDoIPick said:
I am billing CC for anyone that I am admitting for lactic 2 or higher. IDC if it's from sepsis, dehydration, Cyclical vomiting etc. you (proverbial you) can leave RVUs on the table that's fine.

SIRS + source = sepsis

Sepsis + end organ dysfunction (lactic over 2) = severe sepsis

CMS is cutting our pay 3% in 2025 and some people wanna play the "spirit of critical care" game lol.
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Learn the 2023 documentation guidelines.. use them to get paid what we are worth.. critical care sure.. but avoid the 3s and push the proper patients to 4 and then to 5.. again when appropriate..
 
EctopicFetus said:
Learn the 2023 documentation guidelines.. use them to get paid what we are worth.. critical care sure.. but avoid the 3s and push the proper patients to 4 and then to 5.. again when appropriate..
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Yup I hardly ever have 99283
 
What we think of as
WhatJobDoIPick said:
Yup I hardly ever have 99283
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My spread:
99281: 0%
99282: 0%
99283: 2.9%
99284: 43.8%
99285: 41.1%
99291: 10.8%

I have more 4s and fewer 5s than my group average. CC time is minimally above group avg. As alluded to earlier though (different thread maybe?) my $/hr is very high compared to group avg despite my 4:5 ratio because of volume. I probably could convert a bunch of those 4s into 5s with additional testing or a higher admission rate, but the loss of volume would definitely be a hit to the bottom line and not a benefit.
 
WhatJobDoIPick said:
Not sure the exact things being billed but

1) appy or chole meeting sirs criteria (maybe it's just mild fever and leukocytosis) is sepsis and I'm billing cc for that no matter what

2) transfer for stable trauma admissions is getting CC as I am transferring to a higher level of care
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1. SIRS criteria alone isn't sepsis anymore i.e. uncomplicated sepsis is not critical care. Severe sepsis or better is critical care. 90% of appy and chole have stone cold normal vitals. You should not get a lactate on these people to find sepsis that isn't there.

2. Sometimes I have to transfer a patient with three rib fractures who needs a day of pain control. This is not critical care.
 
Mount Asclepius said:
Not technically per the CMS definition. Transaminitis doesn’t meet the definition. Bilirubin greater than 2 does. It may be another one of those classic arbitrary whole number cutoffs in medicine that doesn’t necessarily have the best evidentiary support, but it’s what is used for CMS criteria.

I wouldn’t bill critical care on a hypothetical ‘stable’ 40ish year old patient with cholecystitis, a HR of 92, WBC of 13, minimal transaminitis, bilirubin of 2.1 and a lactate of 2.2 that you admit to the med-surg floor overnight with plan for cholecystectomy in the morning. Some might. I don’t think that is the spirit of critical care billing or consistent with a few standard critical care billing guidelines.

For a septic patient with a lactate greater than 4, significant tachycardia with a HR greater than 120, or hypotension with SBP less than 90 or MAP less than 65, then I think very justified. You don’t see those abnormalities though with most cholecystitis. More likely with cholangitis or severe pancreatitis. Occasionally with cholecystitis in patients with advanced age.

I’m just making a clinical point that most patients with cholecystitis aren’t septic. Same goes for appendicitis patients. I’m also making the billing point that I don’t think billing critical care on most cholecystitis patients is justified. There is a good chance you’ll be able to get away with it, but it’s sketchy. I haven’t been through an audit personally, but wouldn’t want to try to defend it. I even say this as someone who is in the higher side of critical care billing in our group and fully believes in maximizing critical care billing.
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The bili 2.1 and elevated lactate I would bill CC as this patient has severe sepsis per definition.
 
WhatJobDoIPick said:
I am billing CC for anyone that I am admitting for lactic 2 or higher. IDC if it's from sepsis, dehydration, Cyclical vomiting etc. you (proverbial you) can leave RVUs on the table that's fine.

SIRS + source = sepsis

Sepsis + end organ dysfunction (lactic over 2) = severe sepsis

CMS is cutting our pay 3% in 2025 and some people wanna play the "spirit of critical care" game lol.
Click to expand...
Why are you even getting a lactate or admitting cyclical vomiting
 
Brigade4Radiant said:
so whats the thing that converts level 3 to 4s and 5s?
Click to expand...
Discussed above. My 3 to 4 comment:

forums.studentdoctor.net

I like treat and street patients

Also it's infinitely less ****ty than EM, at least locally. My mental health is 200% improved getting out of a malignant SDG. Never going back. I thought all SDGs were amazing to work for once you hit partner?
forums.studentdoctor.net forums.studentdoctor.net

4 to 5... Interpret 2 imaging studies and give IV opioids, benzos or droperidol/haldol.

Or

Same drugs and 1 imaging study plus 3 labs.

Or

Either set of tests listed above plus admit.

Or

Labs plus cxr for ACS rule out and document you considered admission but didn't admit because xxx.
 
TooMuchResearch said:
1. SIRS criteria alone isn't sepsis anymore i.e. uncomplicated sepsis is not critical care. Severe sepsis or better is critical care. 90% of appy and chole have stone cold normal vitals. You should not get a lactate on these people to find sepsis that isn't there.

2. Sometimes I have to transfer a patient with three rib fractures who needs a day of pain control. This is not critical care.
Click to expand...

If the hospital is saying "by definition we are a low level of care and cannot deal with trauma that requires admission" I am for sure going to bill critical care for the time it takes to coordinate the transfer to get them to a "higher level of care."

Same goes for the tiny ass SDH that the hospitalists won't admit.

TooMuchResearch said:
Why are you even getting a lactate or admitting cyclical vomiting
Click to expand...
Intractable vomiting with tachycardia, electrolyte disturbance requiring fluid resuscitation plus minus lactate over 2 = admit with critical care

TooMuchResearch said:
Are you saying SIRS is severe sepsis? Not for several years.
Click to expand...

SIRS plus source = sepsis

Sepsis plus end organ dysfunction (simple as lactic over 2) = severe sepsis.

I am billing CC for both, always.
 
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