RVU based compensation

[thegenius]

It’s the possibility of decompensation.
Maybe it is semantics we are discussing but another way to look at it as I was told by a billing company.. if you have to stop what you are doing to see that patient immediately then its critical care.

That's a good way to look at it.

I never bill for < 30 minutes unless it's a STEMI, or major trauma that gets whisked away immediately to the cath lab or surgery. If they are in the department for 22 minutes then taken to the cath lab / OR, I bill for 22 minutes. If they get whisked away at 38 minutes, I bill for 38 minutes.

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[deleted859535]

That's a good way to look at it.

I never bill for < 30 minutes unless it's a STEMI, or major trauma that gets whisked away immediately to the cath lab or surgery. If they are in the department for 22 minutes then taken to the cath lab / OR, I bill for 22 minutes. If they get whisked away at 38 minutes, I bill for 38 minutes.

Except... CCT coding requires 30 or more at minimum, so is there any benefit in billing 22 minutes? Maybe I'm ignorant of something.

 

[thegenius]

Except... CCT coding requires 30 or more at minimum, so is there any benefit in billing 22 minutes? Maybe I'm ignorant of something.

It allows you to bill at the highest ESI level, so you don't have to have all the ROS or PE elements to satisfy ESI 5.

99285 - highest complexity ED case is 4.9 RVUs.

To bill at 99285 you need to have like 8 ROS, 10 PE, medically complex decision making, etc. For the STEMI that comes in you probably are not going to have time to gather all that info....so it's possible that your STEMI may be downcoded to 99284. However if you bill CC for 25 minutes, it "bumps" the complexity of your chart to 99285.

And obviously if you are more than 30 minutes, then you get an extra 2.2 RVUs for the 99291 CC time.

 

[EctopicFetus]

That's a good way to look at it.

I never bill for < 30 minutes unless it's a STEMI, or major trauma that gets whisked away immediately to the cath lab or surgery. If they are in the department for 22 minutes then taken to the cath lab / OR, I bill for 22 minutes. If they get whisked away at 38 minutes, I bill for 38 minutes.

But your time includes talking to the doc, doing the chart etc. I get that you do it that way but to be clear it is your method and not some rule.

 

[deleted859535]

It allows you to bill at the highest ESI level, so you don't have to have all the ROS or PE elements to satisfy ESI 5.

99285 - highest complexity ED case is 4.9 RVUs.

To bill at 99285 you need to have like 8 ROS, 10 PE, medically complex decision making, etc. For the STEMI that comes in you probably are not going to have time to gather all that info....so it's possible that your STEMI may be downcoded to 99284. However if you bill CC for 25 minutes, it "bumps" the complexity of your chart to 99285.

And obviously if you are more than 30 minutes, then you get an extra 2.2 RVUs for the 99291 CC time.

Ah, I see what you're getting at. I historically have been able to hit elements required for a 99285 on the STEMIs in pretty quick fashion but point well taken for the STEMI/stroke/more involved trauma pages where I don't.

 

[southerndoc]

It allows you to bill at the highest ESI level, so you don't have to have all the ROS or PE elements to satisfy ESI 5.

99285 - highest complexity ED case is 4.9 RVUs.

To bill at 99285 you need to have like 8 ROS, 10 PE, medically complex decision making, etc. For the STEMI that comes in you probably are not going to have time to gather all that info....so it's possible that your STEMI may be downcoded to 99284. However if you bill CC for 25 minutes, it "bumps" the complexity of your chart to 99285.

And obviously if you are more than 30 minutes, then you get an extra 2.2 RVUs for the 99291 CC time.

Documenting that history and review of systems are limited due to acuity of condition will satisfy most of your level 5 charting requirements.

 

[martvubo]

In my time working as a scribe for a CMG (i.e. maximizing billing while also covering their ass wrt fraud), we also coded charts. We were given more detailed and explicit instructions, but there were two relevant things I remember:

If something to the effect of "This patient was seen immediately due to [relevant concern; e.g. at a trauma activation this would be the possibility of injuries, including occult ones, that could pose threat to life or limb]" is in the chart, whether it's on arrival or due to worsening condition (e.g. called to bedside by nurse/family/RT etc) = this is at least an E/M level 5 chart. Diagnosis, MDM, ROS, # of HPI elements were all irrelevant to this.

If that appears in the chart and the doc spent >30 minutes on ANYTHING related to the patient's visit in the ER (other than the stuff already included in CC bundle-- so it would include time for stuff like chart review, taking to family and consultants, placing orders, reviewing diagnostics, reassessing) = this is a critical care chart. Final diagnosis is irrelevant to this.

 

[deleted547339]

It’s the possibility of decompensation.

Critical Care FAQ

CPT currently defines a critical illness or injury as an illness or injury that acutely impairs 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 are defined as a physician's direct delivery of medical care for a critically ill or critically injured patient. It involves decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient's condition. Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure.

CMS adds that in order to qualify as critical care 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."


Note that CPT and CMS are slightly different. Simply if a trauma shows up as an activation, there is a high likelihood of deterioration (Otherwise it’s wouldn’t be a trauma). Maybe it has to do where we work. In residency we had trauma red, yellow and green. The greens were like straight mvas and no trauma surgeon would come down. The yellows were your standard type traumas and the reds were the near codes. As an attending we just had traumas we activated and the green type traumas where they wouldn’t even go to our trauma bays just into rooms.

Maybe it is semantics we are discussing but another way to look at it as I was told by a billing company.. if you have to stop what you are doing to see that patient immediately then its critical care.

It may be a function of the triage system - y’all may triage better than us, but there’s nothing you posted that changes my mind. I’ve read those definitions before, and I don’t see how someone who isn’t injured seriously hits any of those criteria. If you have no injuries, there is not a high probability of decompensating.

 

[deleted547339]

That's a good way to look at it.

I never bill for < 30 minutes unless it's a STEMI, or major trauma that gets whisked away immediately to the cath lab or surgery. If they are in the department for 22 minutes then taken to the cath lab / OR, I bill for 22 minutes. If they get whisked away at 38 minutes, I bill for 38 minutes.

Remember that charting counts. 22 mins in dept can be 30 mIns total.

 

[martvubo]

It may be a function of the triage system - y’all may triage better than us, but there’s nothing you posted that changes my mind. I’ve read those definitions before, and I don’t see how someone who isn’t injured seriously hits any of those criteria. If you have no injuries, there is not a high probability of decompensating.

I think a trauma activation with no injuries would not satisfy CC requirements based on time alone... but to play devil's advocate:

Since the triage assessment usually isn't an EMTALA-friendly MSE, you technically don't know that there are no injuries until after you've already seen the patient (immediately on arrival). Whatever incident warranted a trauma activation is the injury (e.g. MVA concerning enough to call it as a trauma), and the intervention you're making is the "high complexity decision making" at the very least to assess that there is nothing requiring further intervention (and clear them from the barbaric back board if your local EMS is in the stone age).

 

[EctopicFetus]

I think a trauma activation with no injuries would not satisfy CC requirements based on time alone... but to play devil's advocate:

Since the triage assessment usually isn't an EMTALA-friendly MSE, you technically don't know that there are no injuries until after you've already seen the patient (immediately on arrival). Whatever incident warranted a trauma activation is the injury (e.g. MVA concerning enough to call it as a trauma), and the intervention you're making is the "high complexity decision making" at the very least to assess that there is nothing requiring further intervention (and clear them from the barbaric back board if your local EMS is in the stone age).

I dont think any of us will change our minds but simply we are all talking the same thing. I am not saying a trauma activation would satisfy the time requirement. I am saying that it meets the definition of critical care.

If someone is a trauma activation and requires a trauma surgeon and anesthesia and the ED doc at the bedside at their arrival it is hard for someone to tell me that there isnt a high probability of decompensating. The fact you need 3 docs at the bedside immediately tells me you have a high risk of decompensation. hence the “any patient that interrupts my flow” and I need to see immediately qualifies for critical care. Someone thinks they are at high risk of decompensation. Otherwise they can hang like the sprained ankle.

Whether or not it takes you 30 mins is another story.

 

[martvubo]

I dont think any of us will change our minds but simply we are all talking the same thing. I am not saying a trauma activation would satisfy the time requirement. I am saying that it meets the definition of critical care.

If someone is a trauma activation and requires a trauma surgeon and anesthesia and the ED doc at the bedside at their arrival it is hard for someone to tell me that there isnt a high probability of decompensating. The fact you need 3 docs at the bedside immediately tells me you have a high risk of decompensation. hence the “any patient that interrupts my flow” and I need to see immediately qualifies for critical care. Someone thinks they are at high risk of decompensation. Otherwise they can hang like the sprained ankle.

Whether or not it takes you 30 mins is another story.

We agree. Trauma activation certainly meets the requirement for being "critical enough" regardless of the outcome of your evaluation, I just wanted to draw attention to the fact that CPT 99291 is specifically for 30 to 74 minutes worth of that level of care (the same ACEP FAQ linked above says this as well, I just don't want anyone to get in trouble for billing CC for very short visits if they only read this thread and not the whole FAQ)

 

[southerndoc]

Nobody said to key it in as a 99291. If you have less than 30 minutes of critical care time and document critical care at 22 minutes, it should be billed as a 99285. If you are audited, you can pull those up as saying that not all your critical care time is billed >30 minutes. Therefore, you are being honest in your reported time that is >30 minutes. We keep track of documented critical care time <30 minutes for this reason.