ED Coding and Reimbursement Alert

Question: Does invoking the ED acuity caveat impact assigning critical care for the patient in the following case?

Texas Subscriber

Chief Complaint: Fever and unresponsive

HPI: Unable to attain from patient. This 82-year-old male arrives from a nursing home. He is unresponsive and has a full code order. Report from nursing home is that the onset of symptoms was gradual and persistent. The current symptoms are severe.

ROS: Unable to obtain due to patient unresponsiveness and the severity of the presenting symptoms.

Physical Exam:

Constitutional: Vital signs reviewed. Patient is clearly uncomfortable.
Head: Normocephalic and atraumatic
Eyes: Pupils equal round and reactive to light. No discharge from eyes. Extraocular muscles intact. Sclera and conjunctiva are normal.
ENT: Ears normal to inspection. Nose normal to inspection. Mucus membranes pink, moist and normal in color.
Neck: No midline tenderness. Normal range of motion. No meningeal signs.
Respiratory: Moderate respiratory distress. Breath sounds course bilaterally.
Cardiovascular/Chest: Heart sounds irregular. Chest non-tender.
Abdomen: Abdomen is non-tender, normal bowel sounds. No masses, no distention.
Extremities: Inspection normal. No clubbing or edema. No calf tenderness.
Neurological: No focal motor deficits. Poorly arousable.
Skin: Skin is warm and dry.

Diagnostic Interpretations:

Oxygen saturation is 90%, O2 AMT 100%, O2 Sat is hypoxic
Cardiac monitoring strip interpretation shows rapid atrial fibrillation with a rate varying between 150-160 with ST changes.
EKG shows some diffuse ST-T wave abnormality.

Procedure Notes:

Patient’s left chest wall was prepped with Betadine. Following old landmarks for central line placement, my initial aspiration produced air suggesting the creation of a small pneumothorax. I was able to find central venous access via the subclavian vein and placed a triple lumen central venous catheter.
Chest x-ray pending.
Patient’s left chest wall was prepped with Betadine and a chest tube was placed without complication. Subcutaneous tissue was dissected and a 28 French chest tube was placed in the fourth intercostal space.
Repeat chest x-ray shows expansion of the lung with partial resolution of the pneumothorax.

Critical care time: I spent between 30 and 74 minutes in direct care of this critically ill patient excluding the time spent performing separate procedures.
Disposition: The patient was admitted for inpatient care.

Answer: The requirements for reporting critical care do not include the elements of history, physical exam, and medical decision making as found in the ED E/M codes. So, invoking the acuity caveat is not necessary to account for an incomplete history and physical exam documentation in order to satisfy typical E/M documentation requirements. However, these sickest patients certainly require medical necessity documentation and production of a through chart.

In this case, the urgency of the presenting condition does help meet the first of the two requirements for reporting critical care; that the patient meets the CPT^® definition of critically ill or injured as “an injury or illness that acutely impairs one or more vital organ systems such that there is high probability of imminent or life threatening deterioration in the patient’s condition.”

When determining whether or not a patient is critically ill or injured, the physician should consider the likelihood that they would have a clinically significant deterioration if nothing was done in the next hour. In this case, the documented elements of respiratory distress, irregular heartbeat and unresponsiveness satisfy that first requirement.

The second CPT^® requirement for critical care is that documentation of minimal time thresholds of care of at least 30 minutes must be clear from the medical record. The physician has included a templated statement to that effect, “I spent between 30 and 74 minutes in direct care of this critically ill patient excluding the time spent performing separate procedures.” Of note, some payers will require documentation of an exact time in minutes rather than a range. Because of the procedures provided, the inclusion of the statement that the reported critical care time was net of the time spent of performing those separately billable procedures was a good idea.

You could also report some of the diagnostic studies included in this case (cardiac monitoring and EKG, if the documentation meets the standard of a specific order or standing order protocol for the test followed by a written report. The EKG interpretation appears to be incomplete. Of note, the oxygen saturation interpretation is not separately paid by most payers. Medicare considers this equivalent to reading a vital sign. Also keep in mind that certain procedures (such as the chest x-ray) are bundled with critical care.

On the claim report:

99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes)
36556 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older)
32551 (Tube thoracostomy, includes connection to drainage system [e.g., water seal] when performed, open [separate procedure])
93042 (Rhythm ECG, 1-3 leads, with interpretation and report)