# Critical Care Frustration - subsequent or critical care?



## Trendale (Jun 23, 2010)

One of our biggest confusion and difficulty in coding critical care as well as other E/M's  is the fact that, the physician may not include everything he did in the note, it may be documented elsewhere in the chart, and so, we don't know if we should be hunting for this information that can be in numerous places in the chart, or should it be in the report for that date of service? We were thinking that maybe we should be looking in other places in the chart for the emergent intervention for the critical care. I always went by the golden rule, if it is not documented it never happened, maybe that rule has changed. Anyway, we were also thinking about utilizing the prolonged E/M codes 99356 and 99357 along with the subsequent visit code if we have to down code it from a critical care code. Is that appropriate?  We believe most of these critical care charges submitted by the doctors are really subsequents given the documentation.The following is a  summary sample of a critical care note we usually bill for:

This is how the date of service is set up, another one of our concerns: Progress Note - Critical Care  [18-Jun-2010 10:02]. Is that ok??

It is normally a five page note, with the first  two pages consisting of vital signs. This one in particularly has notation regarding pain, stating, No pain behaviors present. Under Ventilator adjustment, he states, change; Rate decreased; Fi02 decreased. Don't know if that is relevant or helps or not. The patient is on a ventilator. The third page has the exam. The fourth page has the labs. Should we be looking at all of this to determine a critical code??? The fifth page what we really look at to determine the code, which is the assessment/plan: 

Radiology:

Radiology: CXR: BLL infiltrates and effusions.

Prophylaxis:  (Data referenced from "Progress Note - Critical Care" 03-May-2010 11:26)

GI: See meds. 

DVT: See meds.

Assessment / Plan:

Neurologic / Psychiatric: Encephalopathy. 

Cardiovascular: Circulatory collapse

PSVT

Cardiomyopathy (EF 30%)

Equivocal troponin level

On pressors. Aggressive crystalloid and colloid support. 

Pulmonary: VDRF-Intubated

CHF/Pleural effusions

COPD/Pulm HTN/Rhinosinusitis

For trach aspirate. 

Gastrointestinal / Nutrition: ? Acute abdominal catastrophe

Check hepatic profile, amylase/lipase   For abd CT scan. 

Renal / Metabolic: Renal failure: Acute on chronic (sCr 3)-? Dialyzed yesterday

Prostate cancer/BPH. 

Hematologic: Thrombocytopenia 

Leukopenia. 

Infectious Disease: Nosocomial sepsis vs. acute abdominal catastrophe

Empiric Azactam, Diflucan. Zosyn, Zyvox    Arrange ID consultation.  

Shock: See CARD. 

Miscellaneous: Multi organ system failure (respiratory, hematologic, cardiovascular, renal) with profile of sepsis and/or abdominal catastrophe. Course reviewed and discussed with family and Dr.  Prognosis poor.

Physician's Statement:

  Critical Care Time 90 minute(s) This excludes teaching time and all billable procedures. The above plan has been discussed with house staff, nursing and respiratory services

Signed 18-Jun-2010 10:12)

         Authored: Vital Signs/ I&O, Respiratory Support, Physical Examination, Results, Prophylaxis, Assessment and Plan, Physician's Statement

Should we be looking at the meds also to determine the intervention, such as the ones above, IV antibiotics: Azactam, Diflucan, zosyn, etc…?

We are coding pulmonary critical care, the docs are intensivist as well.

We normally code all of the organ failures beginning with pulmonary organ failures :518.81, V46.11,  428.0,  584.9.
The documentation we have been reviewing is mainly dx driven without emergent intervention, and I know that that is not the only factor in determining a critical care code.

Would this be a critical care or subsequent??



This is how all of our critical care notes typically looks like. Please give us your two cents and any supporting documentation  (specifically gearing toward emergent intervention, because they seem to have the required dx's documented and time)that we can show our docs would be greatly appreciated! Thank you very much!


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## Jagadish (Jun 24, 2010)

For me, this is a critical care. Condition is critical, time is documented and there is critical care management. This documentation is sufficient if it is the first day. if it is subsequent day, it would be better to bill a subsequent instead with risk as high.


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## FTessaBartels (Jun 25, 2010)

*Critical care*

This is clearly critical care. Patient has multi organ system failure, is on a ventilator and physician is managing those conditions. 

Whether this is the first day or a subsequent day in the ICU, the patient remains critically ill, the physician is providing critical care, and the physician has documented direct face-to-face time of 90 minutes = 99291 & 99292

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## Jagadish (Jun 25, 2010)

It will be 50-50 to say that the patient is still critically ill even for the second day after the critical care management for the past 24 hours. The criticality should be documented for the second day.


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## mb12345 (Oct 19, 2010)

Just going over this issue with some Neurologists today.  Still dont understand why it's not critical care if they are in the CCU?

Anyway,  does anyone know where I can find an excellent example of critical care services documentation for Neurology for Stroke, Seizure, MYasthenia Gravis or Epilepsy?

Point me in the right direction and I will be eternally grateful!!

Mary Beth


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