ED Coding and Reimbursement Alert

Question: One of our physicians documented critical care time on a patient where CPR and intubation was also performed by the same physician.

She documented 60 minutes of critical care time and specified in the documentation that it was exclusive of time spent on CPR and intubation. The physician’s documentation also specified “Family was updated through the course of her ED course. I personally interviewed and updated daughter and nephew, the legal decision makers”.

A nurse auditor at the hospital questioned the chart as the patient had a total of 12 minutes “alive” time between procedures during the ED course.

The physician advised that she spent the 60 minutes of critical care time for time managing the patient while alive, extensive family discussion and documentation. Unfortunately, the patient did expire in the ED.

Do you think the 60 minutes critical care time is defensible?

Answer: Typically, cases where the patient receives CPR but has resumption of vital signs would make the time threshold for critical care but if the chart shows the patient was only “alive” in the ED for 12 minutes, and CPR or other procedures were being performed during the rest of the time, there would need to be 18 minutes of additional contributing clinical activities.

CPT^® states: “When the patient is unable or lacks capacity to participate in discussions, time spent on the floor or unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care, provided that the conversation bears directly on the management of the patient.”

So you would want to clarify the nature of the family conversation. If they were assisting in the decision making, rather than grief counselling, then those minutes would be important to recognize.

Additional time might include: Reviewing of labs and X-rays, coordination of care, patient reassessments, and chart documentation.

Since the case has come under review query, consult your doctor about the time spent outside of separately billable procedures.