ED Coding and Reimbursement Alert

The coding of critical care services presents a challenge for emergency department coders because one or more of the required descriptors or indications of the urgent and critical nature of the care often are omitted from the physicians notes. The following case study provides an opportunity to revisit the qualifiers for coding critical care for the Medicare and non-Medicare patient.

Chief Complaint: Elevated heart rate.

HPI (history of present illness): The patient is a 42-year-old female brought in by EMS (emergency medical services) with a heart rate of 160 at the nursing home. They noted the patient to be somewhat sluggish. They noted her level of consciousness to be decreased and that she has a fever. The patient is unable to communicate.

PMH (past medical history): PMH is significant for problems related to mental retardation, intestinal obstruction, cerebral palsy and dysphagia, requiring PEG-tube (percutaneous endoscopic gastrostomy). The patient has had colon and ileal resections in the past.

Social History: She is a patient at a rehab facility.

Physical Examination:

Patient Status: An ill-appearing white female. She
is thin.

HEENT (head, eyes, ears, nose and throat): Her eyes are open. She does not respond.

Neck: Shows no JVD (jugular venous distention).

Lungs: Clear.

Cardiovascular: Tachycardic and regular.

Abdomen: Soft. No obvious tenderness.

Buttocks: Shows bilateral gluteal erythema with large draining purulent abscess site. This is the same site where she has had problems with bedsores in the past.

Extremities: Without cyanosis or edema.

Skin: Significant for the cellulitis in the buttocks.

Emergency Department Course: On arrival at 4:55 a.m., we were unable to get any blood pressure. She did have femoral pulses. Her heart rate was 210 to 220. It was wide complex. The suspicion was supraventricular tachycardia (SVT) with aberrancy, and the patient was given adenosine 6 mg IV push. She had spontaneous change to a sinus tachycardia. She was noted to be febrile at 100.5 degrees rectally. At 5:30 a.m., her family arrived. They stated that the patient is usually nonverbal, moans and does not follow commands. They thought she recognized them.

Diagnostic/Laboratory Test Results: Lab work showed multiple abnormalities including an elevated BUN (blood urea nitrogen) of 183, creatinine 4.3, and calcium 7.3. The cardiac enzymes were not elevated. Her white count was 12.9, H&H (hemotocrit and hemoglobin) 7 and 22. EKG (electrocardiogram) after conversion with adenosine showed a heart rate of 113 and normal sinus rhythm with no evidence of ischemia. Her urinalysis here showed pyuria with 22 white blood cells.

Level of Service: There was greater than one-half hour direct physician intervention and critical medicine including patient management, consultation with PMD (private medical doctor) and interaction with family.

EDC/MDM: The patient was admitted to [...]