Health Information Management

Tip: Know what does, and does not, qualify as critical care

CDI Strategies, July 23, 2009

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(Editor’s note: CDI specialists may wish to provide the following tip to their physicians in order to gain support for improved documentation in the medical record)
 
Critical care does not include ongoing monitoring of a patient who has stabilized, regardless of how many organs have failed, how many lines and tubes were inserted, or how many devices were instituted. When the patient is stable, it’s not critical care.
Too many physicians don’t realize that we can bill:
  • Critical care delivery by time increments for the first encounter
  • Additional critical care when the patient crashes again
  • A level three subsequent visit for noncritical care in addition to the critical care delivery on the same day
Consider the following case study. A patient presents to the cardiac care unit after a coronary artery bypass graft. The patient is intubated with a left ventricular assist device still in place and receives low-dose dopamine for renal perfusion. The patient’s vital signs are stable with a little hypotension due to lack of vascular tone; however, it is easily controlled. The external pacer is in place, chest tubes are in place to underwater seal, and diluted urine is flowing through the Foley. A physician accepts the patient and performs an evaluation. The patient is not critically ill. However, the patient is on a respirator, and the physician manages that respirator.
 
The patient does not have acute respiratory failure; writing the words “acute respiratory failure,” means a condition exists that involves the respiratory tree due to a disease process. This is not the case, and the presence of the words gives the heart surgeon a black mark. The condition counts as a complication of the surgery.
 
The following are examples of conditions that necessitate critical care:
  • Acute myocardial infarction with acute pulmonary edema
  • Respiratory failure or cardiac arrest with cardiopulmonary resuscitation
  • Septic shock or hemorrhagic shock
  • Ventricular tachycardia with cardiogenic shock
In these situations, the patient actively experiences clinical conditions requiring physicians to administer treatments or help others administer treatments, perform bedside procedures, insert monitoring devices, and watch the effects of treatments. Without these interventions, the patient would die.
 
There are two general functions that physicians perform in an intensive care unit (ICU). The first is the management of complex and ill patients to maintain their stability or prevent decompensation. The second is critical care. 
 
The difference between the two is significant from an ethical as well as a financial viewpoint. Critical care delivery refers to care for which a hospitalist or intensivist can bill a critical care CPT code in the 99291–99292 range with code 99291 for the first hour and code 99292 for each subsequent half hour. We may report code 99292 more than once per day. For ICU services, we can also report subsequent visit codes (99231–99233) and consultation codes (99251–99255), as appropriate.
 
The definition of critical care helps us determine when we can report these codes. In some instances, we may be able to report multiple codes per day. Critical care refers to services rendered, either immediately at the bedside or in some other location where care is delivered in the unit, for patients with life-threatening issues that, when left untreated, could cause death.
 
After the practicality of doing what has to be done is over, proper documentation of what physicians did, what physicians thought, or what physicians concluded is essential. The importance of documentation is a subject many physicians don’t learn in medical school.
 
Editor’s Note: This issue’s tip comes from Robert S. Gold, MD, ACDIS Advisory Board Member, founder of DCBA, Inc., in Atlanta, a consulting firm that provides physician-to-physician programs in clinical documentation improvement, and was first published in the ACDIS sister publication Medical Records Briefing. Reach him via e-mail at DCBAInc@cs.com.



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