# admt code vs critical care code



## Cynthia A (Sep 24, 2009)

This is the screnerio

the patient is being admitted and the hospitialist is doing the initial H/P which requires a E/M code 99221- 99223.   The same doc the same H/P note the patient is deemed critical care.

my question is
Do i use the admit code 99221 - 99223 or do i use the critical care code 99291?


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## LLovett (Sep 24, 2009)

Can you post the note?

Laura, CPC, CEMC


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## Cynthia A (Sep 24, 2009)

CHIEF COMPLAINT:  Bright red blood per rectum and shortness of breath.



HISTORY OF PRESENT ILLNESS:  This is a 41-year-old female with past medical

history significant for gastric bypass surgery and possible hysterectomy.

She is currently intubated and sedated in the ICU, and history is per the

family but somewhat limited.  The patient also is noted to have a prior

history of narcotic drug abuse, but per the family currently does not.  The

family states that the patient for the past several days has been having

bright red blood per rectum for several episodes.  Denies hematemesis or

coffee-ground emesis.  They deny nausea and vomiting.  She has been feeling

lethargic and weak and dizzy.  There is possible syncopal episodes but very

unclear.  The night before admission the patient was complaining of severe

shortness of breath.  The patient was due to have an appointment today with

her hematologist for "anemia."  However, the husband felt that the patient

looked ill and brought her to the emergency room.  In the emergency room,

she was noted to be severely acidotic with acute renal failure and severely

anemic and therefore was intubated.  Per the family, the patient denies

abdominal pain over the past week.  They have noted that she is a little

bit lethargic and possibly confused over the past several days.  Otherwise

the family does not seem to know too much in regards to any history

pertinent to the current episode for admission.



PAST MEDICAL HISTORY:

1. History of gastric bypass.

2. Anemia.

3. Possible hysterectomy.

4. Cholecystectomy.

5. Prior history of narcotic abuse, now not abusing narcotics per the

   family.



MEDICATIONS:

1. Estrogen

2. Iron



ALLERGIES: NO KNOWN DRUG ALLERGIES.



FAMILY HISTORY:  Per the family significant for lupus.



SOCIAL HISTORY:  Per the family.  The patient does not smoke or drink.

However, the patient is currently intubated and I cannot confirm or deny

this.



REVIEW OF SYSTEMS:  Is currently unobtainable due to the patient's

intubated and sedated status.



VITAL SIGNS:  On admission, temperature 37.1 degrees, heart rate of 127,

blood pressure 110/52, respiratory rate of 28, saturating 97% on

assist-control ventilation at 100% FIO2.



EXAMINATION:  GENERAL:  The patient is a little bit agitated, but is

currently intubated and sedated.

HEENT:  Normocephalic, atraumatic with an ET tube inside her mouth.  The

sclerae are pale.

HEART:  Tachycardic without murmurs.

LUNGS:  Clear to auscultation bilaterally, anteriorly.

ABDOMEN:  Is mildly firm with hypoactive bowel sounds.  There are several

incisional scars from the patient's prior surgeries.

LOWER EXTREMITIES:  Show no edema.  Dorsalis pedis pulse 2+.  Her nail beds

are pale.

LYMPHATIC:  I do not appreciate any clavicular, cervical, axillary or

inguinal lymphadenopathy.

PSYCHIATRIC:  I cannot assess at this time due to her intubated and sedated

state.

NEUROLOGIC:  Cannot assess actually due to her intubated and sedated state.



MUSCULOSKELETAL:  Cannot accurately assess due to her intubated and sedated

state.

SKIN:  Appears warm, dry and intact.



LABORATORY VALUES:  Of significance on admission, white blood cell count of

45.7, hemoglobin of 4.8, hematocrit of 16.2, MCV 72, platelets of 828.

Differential of 88% segs, 4% bands 5% lymphs.  PT of 24.8, INR of 2.1,

glucose 135, BUN 27, creatinine 2.37, sodium 137, potassium 4.5, chloride

105.  CO2 is less than 5.  Anion gap is read as greater than 31, calcium

8.3, albumin 3.0, AST 85, ALT of 100, alk phos of 89, bilirubin 1.2.  ABG

done in the emergency room after intubation shows pH of 7.060, PCO2 13.1,

pO2 of 485 on 100% FIO2 with settings of assist control, the rate of 16,

tidal volume 450, PEEP of 5.  A venous lactic acid is 9.2.



IMAGING:  Currently, the only available imaging is a chest x-ray

postintubation which shows a satisfactory ET tube as well as a right

central line placement placed satisfactorily.  No EKG is shown in the

computer system.



ASSESSMENT/PLAN:  A 41-year-old female here with severe anemia,

ventilator-dependent respiratory failure, severe leukocytosis and severe

acidosis.

1. Ventilator-dependent respiratory failure.  The patient is currently

   intubated and we will consult with pulmonology for further assessment.

   I suspect she will require continued ventilation management due to her

   severe acidosis.  At this time it is unclear what is the cause of this

   acidosis.

2. Severe anemia.  She will be transfused with packed red blood cells.  She

   will be given FFP as necessary.  There is a history of bright red blood

   per rectum.  A stat CT scan will be obtained of the abdomen and pelvis

   to if there is any ischemic component causing dead bowel or something

   similar.  Gastroenterology has been consulted for possible scoping.  At

   this time it is unclear if this bleeding is upper or lower; therefore,

   we will initiate Protonix and octreotide drips for the meantime.

3. Gastrointestinal bleeding.  Unclear if this is upper or lower.  We will

   consult gastroenterology.  Octreotide and Protonix drips.  Again, we

   will also check a CT scan to evaluate.

4. Severe anion gap acidosis.  We will check methanol, ethanol levels as

   well as salicylate levels.  Critical care team has discussed with

   nephrology and a dialysis line was be placed for likely emergent

   dialysis.  Drug screen will also be ordered.  At this time it is unclear

   the etiology.

5. Systemic inflammatory response syndrome syndrome.  The patient meets

   criteria upon admission for systemic inflammatory response syndrome with

   elevated white blood cell count and tachycardia.  At this time it is

   unclear if she was infected, but we will check blood cultures as well as

   a urinalysis and urine culture.  No antibiotics currently as there is no

   evidence of infection.  Further medications and other therapies will be

   done pending the CT scans and further evaluation.

6. Coagulopathy.  Her INR is 2.1 for some unknown reason.  We will give her

   vitamin K as well as FFP as necessary to lower this.

7. Acute renal failure.  The patient has elevated creatinine of unknown

   etiology.  Nephrology will be consulted likely for emergent dialysis.

   We will check urine eosinophils.  CT scan will evaluate for

   hydronephrosis.

8. Transaminitis, unclear etiology.  CT scan to image the liver.  This may

   be shock liver.

9. Prophylaxis.  The patient will be on a Protonix drip for

   gastrointestinal prophylaxis.  Sequential compression devices and TED

   hose for deep venous thrombosis prophylaxis.  She anticoagulated

   anyway.



CODE STATUS:  The patient is full code.



Total time spent on this H & P is 70 minutes.







HOSPITALIST FOLLOW UP NOTE



S: intubated/sedated

underwent dialysis for acidosis

earlier blood was reported as positive, but now corrected as no growth



O:

Afebrile

80-90

130/50-60

20

95% on AC/450/16/60%/5



intubated/sedated

right neck central line

right femoral HD line

RRR

CTA anteriorly

Firm/hypoactive

no edema

fingers/toes a little mottled



hgb 11

BUN 10

Cr 0.72

anion gap 13

INR 2.1

low fibrinogen

normal FSP

abg 7.555/28/449

ethanol/methanol/ethylene glycol/salicylate negative



A/P:

41yo female



1. VDRF

2. SIRS, erroneous culture report, correct report is currently no growth to date 

3. Severe anemia, resolved

4. Anion gap acidosis, resolved

5. Coagulopathy, ? DIC, but platelets wnl

6. Check CT abd/pelvis with contrast

7. sugars increasing, insulin gtt

8. broad spectrum abx

9. ECHO, TEE and TTE to eval for endocarditis

10. protonix gtt



additional 40 minutes of critical care time spent, following up studies, d/w consultants, updating family


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## LLovett (Sep 24, 2009)

Ok normally I would say that this should be the admit and critical care but I don't feel the second note which is claiming critical care time actually supports critical care. He is calling it critical care but there is nothing to tell us why, just a list of dx. It says he is discussing things but it doesn't say what and with who(consultants).

I would also normally say add the 2 together and bill the admit supported by both but since there is nothing to indicate how much time was counseling and coordinating care I would not feel comfortable leveling based on time either.

I would take the info from both into consideration but I would only charge the admit, leveling based on the combined key elements.

Just my opinion,

Laura, CPC, CEMC


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## Cynthia A (Sep 24, 2009)

Ok so if the documentation meet the criteria for critical care, what code would you use for the intial visit.  99223 or 99291 since you can only have one code for the intial visit. 

I really think what my question is, 

Can you use a critical care code as the initial visit for a hosptial admission?


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## LLovett (Sep 24, 2009)

You could have both. Critical care is not affected by the per day codes. Critical care would not be used in place of an admit. 

Laura, CPC, CEMC


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## lisigirl (Sep 25, 2009)

I disagree. I think it is clear from the first note that the patient is critically ill (vent supported respiratory failure is just one of the reasons). I would add the time of both notes and bill 99291 and 99292x 2 and forget the intial hospital code.

Lisi, CPC


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## FTessaBartels (Sep 25, 2009)

*99291 & 99292*

I would code 99291 and 99292* x 2 *because the patient is critically ill, and the physician is providing critical care ... 70 minutes in ER/admission and another 40 mintues later in the day for a total of 110 minutes.  (See the chart on pg 19, 2009 CPC Professional Edition)

Discussion with family members and other consultants on the floor/unit is considered direct patient care in the inpatient setting. 

I would not use the initial hospital visit code at all. 

Just my opinion.

F Tessa Bartels, CPC, CEMC


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## LLovett (Sep 28, 2009)

*Depends on your comfort level*

My opinions and advice are based on CMS guidelines and the fact I work at a place that is in trouble for not following them. This (critical care) is one of the areas that have been audited and determined to be incorrect so I am very cautious when using critical care codes.  

Critically ill does not automatically qualify you for critical care. Ventilator management is not critical care. Many of the other issues that could have been critical care are resolved by the second note.

Just my opinion,

Laura, CPC, CEMC


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