Is a Nonrebreather a critical care action (COVID resp failure & critical care documentation)

[theWUbear]

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Wondering if you guys bill critical care for COVID-19 acute hypoxemic respiratory failure patients that are admitted on non-rebreather

The chief complaint of resp distress is worthy of CC
The diagnostic workup is worthy of CC
The final diagnosis is worthy of CC

The intervention: most CC billing guides say that for resp issues, one should consider CC billing if the patient requires NiPPV/high flow or intubation. they do not mention NRB as a critical intervention. Then again, as simple as a NRB may be, by the definition of CC (intervening in a way in which the patient would risk serious harm or death if the intervention wasn't perform), the NRB seems to pass muster

 

[turkeyjerky]

Wondering if you guys bill critical care for COVID-19 acute hypoxemic respiratory failure patients that are admitted on non-rebreather

The chief complaint of resp distress is worthy of CC
The diagnostic workup is worthy of CC
The final diagnosis is worthy of CC

The intervention: most CC billing guides say that for resp issues, one should consider CC billing if the patient requires NiPPV/high flow or intubation. they do not mention NRB as a critical intervention. Then again, as simple as a NRB may be, by the definition of CC (intervening in a way in which the patient would risk serious harm or death if the intervention wasn't perform), the NRB seems to pass muster

Yeah, I would consider a NRB to be 'high flow' oxygen.

We've been using HFNC for these patient for some time now, surprised you guys are still limited to NRBs. Or do you go NC->NRB->HFNC->NIV->vent?

 

[Fox800]

Yes I would.

As an aside, I wouldn’t admit someone on a nonrebreather unless they were comfort care/end of life type thing and weren’t a HFNC/BiPAP candidate for some reason. It’s a temporizing move for respiratory failure.

If they need an NRB they‘d probably be better served with HFNC or BiPAP.

 

[southerndoc]

Wondering if you guys bill critical care for COVID-19 acute hypoxemic respiratory failure patients that are admitted on non-rebreather

The chief complaint of resp distress is worthy of CC
The diagnostic workup is worthy of CC
The final diagnosis is worthy of CC

The intervention: most CC billing guides say that for resp issues, one should consider CC billing if the patient requires NiPPV/high flow or intubation. they do not mention NRB as a critical intervention. Then again, as simple as a NRB may be, by the definition of CC (intervening in a way in which the patient would risk serious harm or death if the intervention wasn't perform), the NRB seems to pass muster

It's not what you do that counts. The patient could be made palliative care and get no oxygen. It's the risk that counts. You have a patient who is so hypoxemic that they require high-flow oxygen. I would say that is an immediate threat to life and thus qualifies for critical care.

 

[deleted547339]

It's not what you do that counts. The patient could be made palliative care and get no oxygen. It's the risk that counts. You have a patient who is so hypoxemic that they require high-flow oxygen. I would say that is an immediate threat to life and thus qualifies for critical care.

I don’t think that is correct. I’m pretty sure critical illness in the absence of therapy does not merit critical care billing. I don’t think watching someone die bills more than a level 5.

 

[deleted547339]

It's not what you do that counts. The patient could be made palliative care and get no oxygen. It's the risk that counts. You have a patient who is so hypoxemic that they require high-flow oxygen. I would say that is an immediate threat to life and thus qualifies for critical care.

At least that’s what I’ve been told by our icu medical director. I’ve been told that any CC billing gets kicked back when we withdraw, unless you’re actively resuscitating then change GOC. I may be wrong, but I always bill 99233s on those.

 

[Fox800]

“If a clinic doctor would call an ambulance to send the patient to the ED, it’s probably critical care.“

 

[Rekt]

Should almost never admit a NRB unless it's a DNI/Palliative measure. Put them on NIPPV or tube them. Or a lot of times you can just titrate them magically to NC since a lot of times these patients are inappropriately placed on NRB in the field in the first place.

 

[Fox800]

Should almost never admit a NRB unless it's a DNI/Palliative measure. Put them on NIPPV or tube them. Or a lot of times you can just titrate them magically to NC since a lot of times these patients are inappropriately placed on NRB in the field in the first place.

Yep. 9/10 times, you can take off the NRB that EMS put on and the patient is doing just fine on like 0-3 liters by nasal cannula...

 

[WilcoWorld]

I don’t think that is correct. I’m pretty sure critical illness in the absence of therapy does not merit critical care billing. I don’t think watching someone die bills more than a level 5.

It does if you treat their dyspnea with comfort measures (like a PCA) as they die.

 

[deleted6669]

“If a clinic doctor would call an ambulance to send the patient to the ED, it’s probably critical care.“

We have clinic docs who call 911 for patients who show up in their waiting room with normal vitals and a cough who "might have covid". Yes, seriously. "Because they need to be evaluated in a negative airflow setting".

 

[Birdstrike]

Wondering if you guys bill critical care for COVID-19 acute hypoxemic respiratory failure...

You didn't need to go past your first sentence. Yes that's critical care. Of course there are exceptions, like DNRs. But you're an ER doctor. If someone comes to see you for respiratory failure and you're treating it, you should feel confident billing critical care 100% of the time. If anyone tells you it's not "critical" and you can't justifiably bill critical care, then they shouldn't have sent them in respiratory failure to an Emergency Department. Cases of people in respiratory failure billed as critical care are not the cases where doctors get charge for insurance fraud. Billing all your patients as critical care as a money grab without regard to documentation? Fraud. Billing for procedures you didn't do? Fraud.

Billing critical care for respiratory failure that you're treating? Not fraud.

Check with your group's billing department. I bet they're not downcoding these to level 5's. They're probably upcoding many more 5's to critical care. ER physicians chronically under coding, greatly outnumber those that overcode.

 

[deleted547339]

You didn't need to go past your first sentence. Yes that's critical care. Of course there are exceptions, like DNRs. But you're an ER doctor. If someone comes to see you for respiratory failure and you're treating it, you should feel confident billing critical care 100% of the time. If anyone tells you it's not "critical" and you can't justifiably bill critical care, then they shouldn't have sent them in respiratory failure to an Emergency Department. Cases of people in respiratory failure billed as critical care are not the cases where doctors get charge for insurance fraud. Billing all your patients as critical care as a money grab without regard to documentation? Fraud. Billing for procedures you didn't do? Fraud.

Billing critical care for respiratory failure that you're treating? Not fraud.

Check with your group's billing department. I bet they're not downcoding these to level 5's. They're probably upcoding many more 5's to critical care. ER physicians chronically under coding, greatly outnumber those that overcode.

Can you upcode a level 5 to CCM? If you don’t specify how much time you spent, I would think you couldn’t.

 

[theWUbear]

Thanks all


Those who noted never admitting people on non-rebreathers - this is adage I was taught well in residency and I have always adhered to completely - until the Covid era - these aren't the COPDers who will oxygenate but fail ventilation and retain CO2 without the positive pressure of BiPAP, sometimes the 15L is what they need vs 30 on high flow. I'm not missing anything here if the issue is just hypoxemia and the 15L corrects it and the patient is comfortable, am I?

 

[Buckeye1992]

How do you transport them in department. with a NRB? Love when EMS brings in COVID pts on NRB and spews it everywhere.

 

[Birdstrike]

Can you upcode a level 5 to CCM? If you don’t specify how much time you spent, I would think you couldn’t.

I suppose if you didn't specify it, they'd have to contact you and ask you to amend the chart. Unless they can do the same by looking at the time stamps (?) . I don't know. I suppose it all depends on how aggressive the billing department wants to be. Some may leave money on the table routinely. Some may rework your coding on the back end. Some may not. I don't know. There's a lot of variation. But it's not a world I live in daily and I usually only interact with billing when they want me to amend a chart to capture a higher level of service or they need me to square my charting with what they want to bill.

 

[Rekt]

Thanks all


Those who noted never admitting people on non-rebreathers - this is adage I was taught well in residency and I have always adhered to completely - until the Covid era - these aren't the COPDers who will oxygenate but fail ventilation and retain CO2 without the positive pressure of BiPAP, sometimes the 15L is what they need vs 30 on high flow. I'm not missing anything here if the issue is just hypoxemia and the 15L corrects it and the patient is comfortable, am I?

15L NRB is essentially peri intubation if they truly need it. It's unlikely you caught the patient on the mend since they presented. Especially with covid the patient will likely have increasing oxygen requirements. HFNC actually takes a sec to set up/get equipment and is not a rescue measure anyway. You're giving the patient a chance to not end up tubed on the floor. Not to mention you get some PEEP with a HFNC as well, which will help decrease O2 requirements in the setting of Covid. Also just because it's HF doesn't mean you can't titrate it less than 15L as well if they start improving and can bridge the gap of maxing on 5L nc to hf. I'd also argue with hf/bipap you'll have much stricter control of how much they actually getting. I'd bet a ton of the actual oxygen is wasted with a NRB compared to NIPPV at similar settings. Half the time you walk in it's hanging halfway off their face. Imagine them sitting upstairs decompensating like this.

Ultimately probably not wrong but not the best decision imo.

 

[RoyBasch]

Agree with the above.

Generally a NRB is a bridging or temporizing measure while you initiate more logistically complicated support. I'm not gonna say there is never an exception, but generally most patients who are hypoxic enough to need a NRB will also be at or soon in clinical respiratory failure and need some more support, either HFNC, NIPPV, or intubation.

And I would say any patient who is that sick--who isn't palliative--is going to be critical care as they have respiratory failure, which is a hallmark of critical illness.

 

[BoardingDoc]

While I enjoyed reading all of the nuanced answers above, I don't know why it's that complex. If you need >6L NC to maintain an appropriate sat, I don't care if you're using BiPAP, an ETT or a NRB. You're in hypoxic respiratory failure which definitionally meets criteria for critical care.

 

[Mushdoc]

While I enjoyed reading all of the nuanced answers above, I don't know why it's that complex. If you need >6L NC to maintain an appropriate sat, I don't care if you're using BiPAP, an ETT or a NRB. You're in hypoxic respiratory failure which definitionally meets criteria for critical care.

Isn't any new oxygen requirement technically acute hypoxemic respiratory failure? Even 2L NC?

 

[Fox800]

Isn't any new oxygen requirement technically acute hypoxemic respiratory failure? Even 2L NC?

Well, our hospitalists certainly chart it as such.

But they don't bill critical care for it...

 

[turkeyjerky]

Isn't any new oxygen requirement technically acute hypoxemic respiratory failure? Even 2L NC?

Yup. Honestly the weirdest thing imo. Like lumping in cardiogenic shock with AHA 1 heart failure

 

[alpinism]

Hypoxemic respiratory failure is a PO2 under 60 on room air not a certain level of O2 supplementation.

You can put someone on NRB but if they've got normal PO2 its not technically hypoxemic respiratory failure.

 

[Fox800]

Hypoxemic respiratory failure is a PO2 under 60 on room air not a certain level of O2 supplementation.

You can put someone on NRB but if they've got normal PO2 its not technically hypoxemic respiratory failure.

Multiple hospitalists across multiple states/sites are billing 2 liters by nasal cannula to maintain normal SPO2 as "acute hypoxic respiratory failure". So somewhere, someplace, this is getting taught and reinforced.

 

[southerndoc]

Multiple hospitalists across multiple states/sites are billing 2 liters by nasal cannula to maintain normal SPO2 as "acute hypoxic respiratory failure". So somewhere, someplace, this is getting taught and reinforced.

If they have an O2 saturation of 90% on room air, then their pO2 is pretty much 60 mmHg based on the oxy-hemoglobin dissociation curve. If they're putting oxygen only on people <90%/pO2 60, then yes, it's acute hypoxemic respiratory failure.

Any patient I admit with COVID with an SpO2 <90% gets diagnosed with acute hypoxemic respiratory failure secondary to COVID-19/SARS if it's confirmed (acute hypoxemic resp failure and suspected COVID-19 if unconfirmed).

 

[Apollyon]

If they have an O2 saturation of 90% on room air, then their pO2 is pretty much 60 mmHg based on the oxy-hemoglobin dissociation curve. If they're putting oxygen only on people <90%/pO2 60, then yes, it's acute hypoxemic respiratory failure.

Any patient I admit with COVID with an SpO2 <90% gets diagnosed with acute hypoxemic respiratory failure secondary to COVID-19/SARS if it's confirmed (acute hypoxemic resp failure and suspected COVID-19 if unconfirmed).

But, "suspected" doesn't make the cut for a LOT of systems. For me (at least), "suspected" was kicked back every single time.

 

[deleted547339]

If they have an O2 saturation of 90% on room air, then their pO2 is pretty much 60 mmHg based on the oxy-hemoglobin dissociation curve. If they're putting oxygen only on people <90%/pO2 60, then yes, it's acute hypoxemic respiratory failure.

Any patient I admit with COVID with an SpO2 <90% gets diagnosed with acute hypoxemic respiratory failure secondary to COVID-19/SARS if it's confirmed (acute hypoxemic resp failure and suspected COVID-19 if unconfirmed).

Sure. But the question is if you’re documenting CC time on someone who is on 2L NC

 

[southerndoc]

Sure. But the question is if you’re documenting CC time on someone who is on 2L NC

No, I'm not. If they require >40% FiO2 acutely, then yes, I do.

 

[KGflyboy]

But, "suspected" doesn't make the cut for a LOT of systems. For me (at least), "suspected" was kicked back every single time.

What do you mean by "kicked back?" If you wrote your diagnosis like this:
1. Acute hypoxemic respiratory failure.
2. Suspected Covid-19 infection.

Would your coders tell you to change it? If so, how so? I don't think we bill for anything "suspected," but sometimes I still put this info in notes because it is clinically useful despite our coders thinking the only purpose of my note is for billing purposes.

Regardless, diagnosis 1 should be enough to support billing critical care whether they they want to bill based on diagnosis 2.

 

[Arcan57]

You didn't need to go past your first sentence. Yes that's critical care. Of course there are exceptions, like DNRs. But you're an ER doctor. If someone comes to see you for respiratory failure and you're treating it, you should feel confident billing critical care 100% of the time. If anyone tells you it's not "critical" and you can't justifiably bill critical care, then they shouldn't have sent them in respiratory failure to an Emergency Department. Cases of people in respiratory failure billed as critical care are not the cases where doctors get charge for insurance fraud. Billing all your patients as critical care as a money grab without regard to documentation? Fraud. Billing for procedures you didn't do? Fraud.

Billing critical care for respiratory failure that you're treating? Not fraud.

Check with your group's billing department. I bet they're not downcoding these to level 5's. They're probably upcoding many more 5's to critical care. ER physicians chronically under coding, greatly outnumber those that overcode.

Why would a DNR invalidate CC? I could see comfort care (maybe), but didn't we get it drilled into us that DNR isn't do not treat?

 

[deleted547339]

Why would a DNR invalidate CC? I could see comfort care (maybe), but didn't we get it drilled into us that DNR isn't do not treat?

Agreed. A lot of my patients are DNR, but simply having a critical diagnosis without intervention is not enough to merit critical care.

 

[southerndoc]

Why would a DNR invalidate CC? I could see comfort care (maybe), but didn't we get it drilled into us that DNR isn't do not treat?

If you see a patient who is critically ill and make them comfort care, then you can bill for critical care. If they are already comfort care when you see them (family freaks out on a hospice patient, calls 911, they come to your ER and you do nothing), then no, you can't bill critical care for that.

 

[Birdstrike]

Why would a DNR invalidate CC? I could see comfort care (maybe), but didn't we get it drilled into us that DNR isn't do not treat?

I think it's a judgement call based on what actions you're taking. DNT or DNR with treatment?

 

[WilcoWorld]

If you see a patient who is critically ill and make them comfort care, then you can bill for critical care. If they are already comfort care when you see them (family freaks out on a hospice patient, calls 911, they come to your ER and you do nothing), then no, you can't bill critical care for that.

As a palliative doc (or if I'm doing a compassionate extubation on an ED shift) I will bill CC time for the time spent managing dyspnea/anxiety/agitation on a patient receiving comfort care if my level of management warrants it.

So if I'm titrating a PCA or pushing boluses of morphine in a critically ill patient - that's critical care time.

Now, if they're a General Inpatient Hospice (GIP) patient, that's a different sort of hospital encounter and a different story. But comfort care =/= hospice.

 

[Apollyon]

What do you mean by "kicked back?" If you wrote your diagnosis like this:
1. Acute hypoxemic respiratory failure.
2. Suspected Covid-19 infection.

Would your coders tell you to change it? If so, how so? I don't think we bill for anything "suspected," but sometimes I still put this info in notes because it is clinically useful despite our coders thinking the only purpose of my note is for billing purposes.

Regardless, diagnosis 1 should be enough to support billing critical care whether they they want to bill based on diagnosis 2.

Yes, the coder would send the chart back, stating that she couldn't code "suspected". That just couldn't be there. The office couldn't fit the peg into the hole.

 

[Rekt]

Yes, the coder would send the chart back, stating that she couldn't code "suspected". That just couldn't be there. The office couldn't fit the peg into the hole.

Most of the time this is true, but you can bill for "Suspected Covid", presumed, likely, etc. There's -an ICD10 for it too.