# Still Critical Care?



## jifnif (Sep 29, 2009)

If I have a patient who is on vent depen.  for six days can we still bill day six as critical care if they are stable?  Our hospitalists have been coding their own work and the first five days of this pt's visit was coded critical care even after stablized due to being on the vent.  Now I have a diff dr on day 6 and she is only billing a subsequent.  Who is correct?


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## FTessaBartels (Sep 29, 2009)

*Stable*

A person may be critically ill and still stable (because they are not getting worse).  

So both physician's may be "correct."  Impossible to really tell without seeing all the actual notes. 

F Tessa Bartels, CPC, CEMC


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## jifnif (Sep 29, 2009)

*Notes for both DOS*

*This note was coded 99233:*
Impression:
-
Vent Dependent Resp Failure - DAY # 6
CAP - Left lower lobe 
Bilateral cavitary lesions in the upper lobe
Hypotension requiring pressors
cirrhosis
Thrombocytopenia
Dehydration
Hyponatremia
Anemia
Malnutrition
Oral candidiasis
Deconditioning
H/O LUNG CANCER POST LUL LOBECTOMY


Plan:
-
vent management per pulmonary
antibiotics per ID
Code level 3 - treat hypotension and arrhythmias
Family meeting 8/5/09 - with no plans for trach
DC TPN - TFs are at goal rate


Note:
-
Pt remains in the ICU on the Vent
Sedated
TPN and TFs cont

Chart reviewed
Case was discussed with multiple consultants
Presently hypotensive - pressors to be restarted.
Case was discussed with POA by pulmonary
Family is OK with treating hypotension and arrhythmias
Plt count is low - but stable
Aristra was started 8/2/09

	Vital Signs
  Date Time 	Temp	Pulse	Resp	B/P	Pulse Ox	O2 Delivery	FiO2
8/3/09 06:00		112					
8/3/09 06:00			25	96/75	99	Mechanical Ventilator	30
8/3/09 04:00	98.0						


Lungs: scattered ronchi and wheezes
Heart: RSR
EXt: thin, no edema


Multivitamins 10	35 mls/hr	8/3/09 0015
ml/Chromium/	Q24H/IV	8/3/09 0400
Copper/Manganese/		
Zinc 1 ml/		
Parenteral		
Electrolytes 20		
ml/Potassium		
Phosphate 15 mm/		
Potassium		
Chloride 20 meq/		
Magnesium Sulfate		
12 meq/Calcium		
Gluconate 4.65		
meq/Sodium		
Acetate 15 meq/		
Potassium Acetate		
10 meq/Thiamine		
HCl 50 mg/Amino		
Acids/Dextrose		

Feeding Tube Type	Dobhoff	8/3/09 0400
Tube Feeding/Supplement Type	Jevity 1	8/3/09 0400
Tube Feeding Rate	45 ml/hr	8/3/09 0400


Pre-admission Medications:
-
Spironolactone 		100 mg daily.
prednisone 			10 mg daily.
Flomax 			0.4 mg daily.  

Darvon 			one tablet q.4h p.r.n. for pain.

*This note from previous day was coded 99291:*

Plan
-
1) Vent Dependent Resp Failure--Remains intubated. CXR pending--may need bronch if worsening or if no improvement. Per family, continue vent, but Level 3 code if status worsens.
2) Cavitary Pneumonia and TB--Cont meds per pulm and ID. AFB PCR pending. HIV resent--pending. Pt with temp 100.0 overnight--will d/w pulm and ID if diagnostic thoracentesis would be of any benefit.
3)Cardiac--Hypotension and CHF--Contuinue careful fluid balance. Cardiology and pulm following. Off pressors at present, though pressures lower today than yesterday.
4)Neuro--Neuro following--likely sx due to hypoxia episode and low perfusion. Weaker on Right side. Made eye contact and making purposeful movements this AM when diprovan off.  
5)Thrombocytopenia--Check HIT panel. For now continue Lovenox. 
6)Anemia-Now at 9.1. Monitor closely.
7) Malnutrition--Continue doboff feeding and trying to wean off tpn
8)Deconditioning
9)DVT proph

Impression
Vent Dependent Resp Failure
Left lower lobe community acquired pneumonia
Bilateral cavitary lesions in the upper lobe
Hypotension requiring pressors
Thrombocytopenia
Dehydration
Hyponatremia
Anemia
Malnutrition
Oral candidiasis
Deconditioning

Subjective
-
Pt remains on vent. When Diprovan off this AM, making eye contact. When nurse said good morning, he mouthed "morning" in response. Family meeting with 3 daughters 2 days ago--agree to Level 3 code status, but continue current level of care. 

Physical Examination
General Appearance: Sedated on vent.
Cardiovascular: Normal S1/S2
Lungs:  +Coarse BS. Decreased at Left base.
Abdomen: Soft, Non-Tender, + Bowel Sounds
Neuro: Sedated
Extremities: No Calf Tenderness, + Edema with mild weeping upper extrem's, No LE edema


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## FTessaBartels (Sep 29, 2009)

*Where's the time spent in critical care on note 1?*

Well, I do NOT see any indication of time spent providing critical care on note # 2 (which was the earlier date).  You MUST have at least 30 minutes of direct critical care documented to use 99291. 

But the main difference seems to be that on the first note (coded 99233) the patient's cares seem to have been restricted to just treating hypotension and arrythmias. If they are cutting back on the intensity of care (even if the patient is still critically ill), then you're not providing critical care any longer. 

I'm not a physician. If the physician tells me the patient is critically ill and he provided critical care for at least 30 minutes, then I code the 99291.  A patient CAN be critically ill on a ventilator for quite some time. The same patient may be still on a ventilator but sufficiently improved to no longer be deemed critical the very next day. So coding 99291 one day and 99233 the next isn't necessarily a problem. 

Also, don't forget that a critically ill patient may receive care by more than one physician; that doesn't mean each of them is providing critical care. (Classic example in our pediatric intensive care unit is the dermatologist called in to evaluate a rash on a child who is on ECMO.  The child is critically ill, but this physician isn't providing critical care.)

Hope that helps.

F Tessa Bartels, CPC, CEMC


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