ED Coding and Reimbursement Alert

Expert reveals the audit technique that leads you to the extra cash

Heads up, ED coders. When you see certain phrases in a physician's notes, chances are you could be billing for critical care rather than settling for the lower reimbursement of standard ED E/M codes.

-We do so much more critical care in the ED than what we bill for. It's unbelievable,- Caral Edelberg, CPC, CCS-P, CHC, told attendees at the recent American Academy of Professional Coders conference in Seattle. To collect critical care dollars -- and stay compliant -- physicians and coders must work closely together, says Edelberg, president and CEO of Medical Management Resources in Jacksonville, Fla.

Red flag that you-re missing critical care cash: Go back to the records and trace your ED patients who were later admitted to the intensive care unit (ICU), Edelberg says. If the bulk of those ICU admissions weren't billed as critical care (99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes; and +99292, ... each additional 30 minutes [list separately in addition to code for primary service]) patients in the ED, you-ve missed the chance to collect those dollars.

-Typically, most ED patients requiring admission to the ICU have had critical care in the ED,- Edelberg says.

-I can guarantee you that many critical care cases are not coded properly because of incorrect documentation,- Edelberg adds. So coders should educate physicians to provide better documentation about time and content so we can submit those critical care claims.

Asthma = Critical Care? Maybe -

To meet the CPT critical care coding criteria, there must be -a high probability of imminent or life-threatening deterioration in the patient's condition.- Critical care does not require unstable vital signs, Edelberg says. Critical care does -involve high-complexity decision-making to assess, manipulate and support vital system function- as well as -to prevent further life-threatening deterioration of the patient's condition.-

This definition opens up many situations that doctors may not recognize as critical care from a coding perspective, Edelberg says. -Asthma attack? Could be critical care.- The same holds true for altered mental status or severe chest pain that the physician manages in the ED with high-level interventions, she adds.

Look for These Terms

If you see these conditions in your physician's note, chances are that he provided critical care and you need to educate your doctors to provide the documentation necessary to submit a critical care claim:

- Significant acidosis

- Anaphylactic shock

- Angina, unstable, aggressive management

- Atrial fibrillation with tachycardia

- Asthma, multiple treatments with more risk

- Blood loss, PRBCs hung, gastrointestinal bleed

- Cardiac arrest

- Comatose/unconscious, unknown cause at presentation

- COPD/CHF severe exacerbation

- Dehydration with significant metabolic blood chemistry changes

- Glasgow Coma Scale below 14

- Head injury, severe, unresponsive

- Hypoxia/hypoxemia

- Unstable vital signs

- Hypernatremia

- Open fracture

- Pneumothorax

- Significant pulmonary edema

- Rapid heart rate requiring IV therapies and/or close  monitoring in ED

- Seizure, new onset or with disorder history, postictal with intensive drug management

- Sepsis/septicemia

- Severe bleeding, requiring transfusion

- Shock-unresponsive patient

- Status asthmaticus

- Status epilepticus

- Stroke

- Suicidal ideation, clear and immediate threat, requiring chemical/physical restraints

- Trauma, multiple, altered consciousness, life or limb threatened.

-Worry- Isn't Critical Care

You should also scan notes for the term -Busy ED,- Edelberg says. That phrase can alert you to the fact that the care was critical, even if the doctor didn't get to the patient immediately. There might have been a car accident and a backlog of patients, for example.

Even as you alert your ED physicians to opportunities documentation requirements, how time is aggregated, and what critical care does not include.

Critical care does not include time spent on separately billable procedures, such as endotracheal intubation and laceration repair, for example.

-And some doctors will overestimate time,- Edelberg says. She tells the story of one well-meaning doctor who documented eight hours of critical care. She said to him, -We have to talk about this because you had 40 other patients whom you took care of during those eight hours.- 

The doctor replied, -You told me critical care was all about how much time I spent thinking about a patient's condition, and I was worrying about him the whole time.-

Consider giving physicians a template that helps them record critical care time, Edelberg says. This strategy tackles the time-overestimation problem and helps them remember to document things like time spent interpreting tests, time thinking about treatment options, and time with the patient's family.

(Note: For a refresher course on critical care coding, see -4 Questions to Ask Before Filing Critical Care Claim- in Vol. 10, No. 5 of ED Coding Alert.)