(Based on Presenting Problem)

Joe Barton, MD, MHMS Oct 30, 2012

 Review specific critical care clinical presentations

 Outline which scenarios may NOT be appropriate for CC time

 Identify documentation and coding requirements

 Explore difference between 99285 and CC

  Ask yourself two questions:

  Was the patient admitted (based on medical necessity) to ICU or taken immediately to the OR? •  If yes: strongly consider CC •  If no: is it really CC? •  If no (and you think it is CC): write a Medical Necessity note

  Will the patient die or deteriorate (quickly) if I don’t do something (quickly)? •  If yes: document CC •  If no: is it really CC? •  If no (and you think it is CC): write a Medical Necessity note

 CPT: CC is the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. •  A critical illness or injury 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.

     CMS: CC involves high complexity decision

making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.

 Must be audit defensible

 Outside of Medicare/Medicaid, CPT rules may be slightly less stringent

 Definitions may “sound the same,” but might be very different!

 Medicare rule will almost always trump CPT

 Considerable overlap and indistinct border between 99285 and 99291 CPT descriptors

 99285 examples tend to suggest a high risk presentation •  MVA and symptoms compatible with intra-

abdominal and extremity injuries

 99291 examples consistent with high risk presentation PLUS actual positive finding •  Auto vs ped with liver lac, pulmonary contusion

 Requires 3 key components •  Within the constraints imposed by the urgency of the

patient's clinical condition and/or mental status   A comprehensive history   A comprehensive examination  Medical decision making of high complexity

 *High Risk* •  High severity presenting problem(s) •  Poses an immediate, significant threat to life or

physiologic function.

 Complicated overdose requiring aggressive management to prevent side effects from the ingested materials

 New onset of rapid heart rate requiring IV drugs

 Active, upper gastrointestinal bleeding

 Patient who arrives immobilized after an MVA with symptoms compatible with intra-abdominal injuries or multiple extremity injuries

 Acute onset of chest pain compatible with classic symptoms of cardiac ischemia and/or pulmonary embolus

 Sudden onset of "the worst headache of life," and complains of a stiff neck, nausea, and inability to concentrate

 New onset of a cerebral vascular accident

 Acute febrile illness in an adult, associated with shortness of breath and an altered level of alertness

  65-year-old male with septic shock following relief of ureteral obstruction caused by a stone

  5-year-old with acute respiratory failure from asthma

  45-year-old who sustained a liver laceration, cerebral hematoma, flailed chest, and pulmonary contusion after being struck by an automobile

  65-year-old female who, following a hysterectomy, suffered a cardiac arrest associated with a pulmonary embolus

  6-month-old with hypovolemic shock secondary to diarrhea and dehydration

  3-year-old with respiratory failure secondary to pneumocystis carinii pneumonia

 At the bedside or in the ED and immediately available to patient

 Requires MD’s full attention, you cannot provide services to any other patient during that period of time

 May be aggregated, doesn’t need to be continuous

  At the bedside or in the ED and immediately available to patient

  Requires MD’s full attention, you cannot provide services to any other patient during that period of time

  May be aggregated, doesn’t need to be continuous

  Time spent in the box reviewing test results or imaging studies counts

  Discussing the critically ill patient's care with other medical staff counts

  CPT says yes to documentation, CMS says no

 What about CMS and CPT description of “immediately available” when patient is in the cath lab or the OR and you’re in the ED?

 Does documenting the record, speaking with family, or other “non-bedside” activity count when the patient is not in the ED?

  The 25 minute door to cath lab patient: maybe

  Pre-hospital cath activation: probably not (controversial)

  CMS: Concurrent critical care services provided by each physician must be medically necessary and not provided during the same instance of time

  CPT: Only one physician/provider may report services for a given hour of critical care, even if more than one physician/provider has rendered critical care to the patient

 Time spent speaking with family members or surrogate decision-makers counts if

•  The patient is unable or incompetent to participate in giving history and/or making medically necessary treatment decisions

•  There is a necessity to have the discussion

•  There is a summary in the medical record that supports this medical necessity

 Time spent speaking with family members or surrogate decision-makers counts if

•  The patient is unable or incompetent to participate in giving history and/or making medically necessary treatment decisions

•  There is a necessity to have the discussion

•  There is a summary in the medical record that supports this medical necessity

 Time that does not count •  Teaching time at the bedside •  Resident time alone at the bedside

 Otherwise, the medical review criteria are the same for the teaching physician as for all physicians

 Documentation must support all CC criteria

 Time that does not count •  Teaching time at the bedside •  Resident time alone at the bedside

 Otherwise, the medical review criteria are the same for the teaching physician as for all physicians

 Documentation must support all CC criteria

 Accurate time statement always required (avoid about or approximately)

 Document 99285 elements or acuity caveat •  These visits potentially can be down-coded to 99284-5 •  ED course should support high complexity MDM and

establish medical necessity

 Document serial assessments and your decision making that involves the organ system at risk

 Document the critical lab, imaging, other study and/or EKG findings and their significance

 Include diagnostic and therapeutic interventions performed and/or considered •  with the “why,” especially if you’re performing

the intervention

 Goal is to impart on paper the likelihood of life-threatening deterioration •  if you didn’t do something on arrival or if you

didn’t intervene on a study result

 Count towards CC time •  Interpretation of cardiac output measures •  Chest x-ray interpretation •  Blood draws, blood gases, and lab data •  ECGs •  Gastric intubation •  Pulse oximetry •  Temporary transcutaneous pacing •  Ventilator management •  Vascular access procedures (outside of central lines)

 Separately billed •  Wound repair •  Intubation •  Chest tubes •  Central lines •  CPR (which is bundled, in and of itself…)

 Patient presents with chest pain and has a 99285 service provided •  While waiting for a bed, he has an episode of

hypotension and run of ventricular tachycardia

 CPT: May report 9928x plus 99291 by same physician on same calendar day

 CMS: if critical care services are required upon arrival into the emergency department, only critical care codes may be reported

 Patient presents with chest pain and has a 99285 service provided •  While waiting for a bed, he has an episode of

hypotension and run of ventricular tachycardia

 CPT: May report 9928x plus 99291 by same physician on same calendar day

 CMS: if critical care services are required upon arrival into the emergency department, only critical care codes may be reported

 Disposition suggesting CC should be considered: •  ICU admit (maybe telemetry) •  Direct to OR •  Death in the ED

 Disposition suggesting this is likely not CC: •  Floor admit •  Discharged home

 Documentation suggesting may not be CC •  “NAD,” Normal VS, “Resting comfortably” – look at the

nursing notes!

  Minimally documented and/or benign ED course that does not support medical necessity

  Psych (generally)

  High risk presentation with subsequent r/o of critical illness/injury

  Urgent call and arrival of specialist is not CC unless necessary time portion of workup was initiated and treated by you

    Abnormal lab values alone do not support CC

•  unless MDM reflects high complexity MDM •  initiation of life-saving assessment/treatment or prevention of a quick

deterioration

  This is when your Medical Necessity statement is actually necessary, but our billers like to see it on all CC charts.

  Minimally documented and/or benign ED course that does not support medical necessity

  Psych (generally)

  High risk presentation with subsequent r/o of critical illness/injury

  Urgent call and arrival of specialist is not CC unless necessary time portion of workup was initiated and treated by you

    Abnormal lab values alone do not support CC

•  unless MDM reflects high complexity MDM •  initiation of life-saving assessment/treatment or prevention of a quick

deterioration

  This is when your Medical Necessity statement is actually necessary, but our billers like to see it on all CC charts.

 Consider CC •  EKG compatible with ischemia with enzyme changes •  Arrhythmias requiring treatment •  Hypotension •  Pain requiring ongoing IV NTG •  Use of IV heparin, lytics •  Immediate dispo to cath lab or ICU

 Probably not CC •  EKG normal and given ASA per protocol •  Repeat EKG, enzymes normal •  SL or topical NTG only (not given parenterally = less risk) •  Dispo home

 Consider CC •  If symptomatic (eg syncope, altered mental status/

neuro signs, chest pain, dyspnea; not simply palpitations)

•  With significant co-morbidities such as ingestion •  Treated with electricity, IV drips or multiple doses of

drugs

 Probably not CC •  PAT converted in field •  Spontaneous conversion in stable patient •  Asymptomatic AF with single bolus of meds

 Consider CC •  Hypertensive emergency end organ(s) affected

(brain, heart, lungs, kidney) •  Treatment ongoing, with ICU admit

 Probably not CC •  Hypertensive urgency •  Incidental finding unrelated to main problem •  May get PO or IV Rx, but floor admit or

discharged

 Consider CC •  Syncope plus a significant co-morbidity •  Arrhythmias (see prior slide!) •  Lower or UGI bleed •  Significant hypovolemia •  Altered mental status or seizure •  Pulmonary embolism •  ICU admit

 Probably not CC •  “Weak and dizzy” •  No significant co-morbidity •  Simple faint

 Consider CC •  Status epilepticus •  Complex febrile •  Context of trauma, OD or ingestions •  ETOH or drug withdrawal

 Probably not CC •  Recurrent •  Noncompliant •  Sub-therapeutic meds

 Consider CC •  Abnormal vital signs requiring treatment •  Any airway issues •  Start/consider TPA •  Rapid assessment and transfer for definitive

treatment at a stroke center

 Probably not CC •  Stable patient with completed stroke

 Consider CC •  CPAP •  High flow oxygen, continuous nebs and ICU admit •  Altered mental status •  Impending respiratory failure documented •  Intubation performed or considered •  CHF with significant worsening of pulmonary edema

or severe dyspnea

 Probably not CC •  2-4 nebs or continuous nebs plus steroids and pt

improves rapidly/clears •  Dispo to floor or home

 Consider CC •  Immediate dispo to OR (AAA, perforated viscus) •  Hemodynamic instability •  ICU admit (bowel ischemia, sepsis)

 Probably not CC •  Appy/diverticulitis: routine and admitted to floor •  Perforated appy or diverticulitis initially

admitted to floor

 Consider CC •  Hemodynamic instability/abnormal VS •  Possible cord injuries •  Unresponsive/altered •  Procedures such as chest tube, intubation •  Dispo to OR or transfer to Trauma Center

 Probably not CC •  Low mechanism in alert patient w/o complaints •  Isolated extremity injuries w/o neurovascular

compromise

 Consider CC •  High lethality agent requiring intervention or

close monitoring •  Seizures, coma, arrhythmias, hypotension

 Probably not CC •  Benign overdose with watchful waiting

 Consider CC •  Stridor, wheezing. hypotension •  IV epi or pressors

 Probably not CC •  IM epi and/or IV steroids and clears

 Consider CC •  Most admitted DKA and/or other metabolic

acidosis admitted to ICU •  Hyperosmolar states (eg coma)

 Probably not CC •  Mild DKA treated in ED and sent home

 Consider CC •  Abnormal EKG •  Symptomatic (eg confusion, muscle weakness) •  Requires IV treatment with active monitoring

(severe hypokalemia) •  Emergent dialysis required •  Acute renal failure with ongoing management

(ongoing fluids, bicarb drip)

 Consider CC •  Sepsis bundle management (central line,

elevated lactate) •  ICU admit •  Immunocompromised patient •  Transplants/cancer patients

 Consider CC •  Any shock-like state •  Altered mental status

 Consider CC •  Hypothermia: either PLUS another problem or

more intervention than passive external re-warming

•  Lightning strike •  CO with signs/symptoms and HBO treatment or

emergent transfer

 Consider CC •  Delirium or organic cause identified plus ICU

admit

 Probably not CC •  Agitation due purely to psych issue

 Always document to support Level 5 billing

 Accurately document time  Write a medical necessity statement if

you think it’s CC

 Questions?