# Critical Care help!



## MandyFlagg (Apr 7, 2011)

I have been working with the provider for a year now because noone else has been able to get through to him.  I have presented numerous articles along with cpt guidelines and CMS guidelines but he is set on billing critical care.  I have problems with most of the notes he is billing and would like some of your expert opinions.  Here are a few examples:
First:
CC 35 min
Pt sedated on vent + tracheal secretions
37.6, 106, 14, 92/42,  98% on 40%

chest: no wheeze, good air extry
cvs: no gallop
abd: soft
ext: no edema

(referenced multiple labs) 
trop: 46     7.5/35/108/27 on vent 
x-ray chest: improving pulmonary edema

Resp failure Acute due to AMI/pulmonary edema
Cardiogenic shock on levopred
AKI
LRI
L hip fx s/p orif
cont. levopred
vent adjusted 
wean as tolerated
tube feeds
type & cross match & transfuse 2 units of PRBC
lasix
watch renal function & lytes
BD
Avelox
pt's family updated about her medical condition
poor prognosis.

Second
CC 35 min
Pt awake tolerating vent minimal trachael secretions, low grade temp 38.2
104, 172/65, 20 100% on 40% FIO2
chest: no wheeze, decreased air exchange
cv: no gallop
abd: nt, + bs
ext: 1+ edema
7.44/46/61/32

(noted many labs)

Acute resp failure - vent dependant
End stage COPD with exacerbation
Anemia
AKI
Fever

IV steroids
vent support
BD
pan-culture - on cefepin, fluconozole, levaquin
tolerating tube feed
transfusion per nephro
EPC cuffs

Thanks! 

Any input would be great!


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## FTessaBartels (Apr 11, 2011)

*Why Do You Think These Are NOT Critical Care?*

Mandy,
Why do you think these notes do NOT qualify as documentation for critical care?

I have my suspicions as to your thinking, but would like to know before I respond.

F Tessa Bartels, CPC, CEMC


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## MandyFlagg (Apr 12, 2011)

*My reasoning*

The reason I do not believe that these would qualify as critical care is because of my interpretation of the rules.  In Publication 100-4, 12, 30.6.12 the definition states: 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.  This to me means that there is an ACUTE, URGENT need for the patient to be seen IE: sudden decline in condition, code, sudden instablility in vitals/status, etc.  Just because the patient is on a vent and that vent needs adjusted does not mean that patient requires "critical care" I know that these patients have respiratory failure however the way these notes are written make me think that that patient has this condition however is stable.

Does that make sense?


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## FTessaBartels (Apr 15, 2011)

*Critically Ill*

I know one physician who wil not bill critical care unless the person is in imminent danger of death.  

But the guidelines do NOT say the person has to be *acutely* in danger. 

For patient number one your documentation includes:
*Resp failure Acute due to AMI/pulmonary edema
Cardiogenic shock 
type & cross match & transfuse 2 units of PRBC
poor prognosis*

For patient number two documentation includes:
*End stage COPD with exacerbation
Fever
pan-culture - on cefepin, fluconozole, levaquin
transfusion per nephro*

In both cases I think you could make an adequate argument that the patient's illness/disease process is acutely impairing one or more vital organ systems ... i.e. critically ill. And that the physician is trying to treat those systems. 

However, all I see for time is :  *CC 35 min*
When I see the abbreviation "CC" I think Chief Complaint.  
I like to see "I spent 35 minutes in direct critical care time with this patient."

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## OCD_coder (Apr 18, 2011)

I would have to agree with Teresa, I found this description on Trailblazer-MCR website.

"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."

The physician must be at the bedside for the full 35 minutes and it appears as if this was documented correctly.  I would agree with Teresa, that it would be better to document out the CC to critical care, that could be a transcriptionist issue - but would be worth the clarification for auditing purposes.


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## MandyFlagg (Apr 19, 2011)

Thanks Ladies,
Maybe my understanding of critical care is mistaken, I was under the impression that the patient had to be unstable to the point that it was a threat to life?  I did not think that if they documented that the patient is sedated and not in any distress that that would more than likely qualify as a high level visit and not critical care.  I have been trying to research this for so long and there is not alot of information out there.  

Again, I really appreciate your help!


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