ED Coding and Reimbursement Alert

Question: We need help coding this chart when the minimum time threshold for critical care seems questionable. What would you suggest?

Texas Subscriber

Chief Complaint

Patient presents with: Cardiac Arrest

I was unable to obtain a clear HPI, ROS from the patient or review their PMH, FH, SH due to acuity of condition (patient not responsive).

HPI Patient is a 67 y.o. male with a PMH of CAD s/p CABG (10/3/2013), A fib on Coumadin, aortic stenosis, mitral regurgitation s/p MVR (10/5/2013), heart failure, pulmonary HTN, s/p gastric bypass (2002) and multiple hernia repairs who presents to the ED via urgent wheel chair transport c/o cardiac arrest. Patient’s wife reports the patient had been feeling fatigued for the past week. He had poor PO intake and increased sleep during this time, but had been taking all his medications. 

He was scheduled to see cardiology today and when he arrived for his appointment he stopped to use the bathrooms in the main lobby. His son helped him into the bathroom because he had been feeling weak previously and required wheelchair assistance when entering the hospital. When the son went to check on him, he found the patient had collapsed on the bathroom floor. The patient was then placed in a wheelchair and brought to the ED at 09:49. 

Past Medical History

Extensive as recorded in nursing notes with a history of numerous cardiac conditions, obstructive sleep apnea, GERD, and gastric bypass surgery.

Family History

Father: Kidney Disease and Alzheimer’s Disease, Mother: Diabetes, Brother: Hypertension Heart Disease

Social History Married, Never Smoker, Alcohol Use: No. Sexually Active: Yes -- Female partner(s). Patient is currently disabled.

Physical Exam

Nursing note and vitals reviewed.

Constitutional: Unconscious. Flaccid.

Head: Normocephalic and atraumatic. 

Mouth/Throat: Oropharynx is clear.  

Neck: Neck supple. 

Cardiovascular: Pulseless.

Pulmonary/Chest: No spontaneous respirations.  

Abdominal: Soft. Bruising over abdomen

Musculoskeletal: Wraps over BLE.   

Neurological: Non-responsive. A&O x 0. 

Skin: Gray in appearance.

ED Course: Patient was brought to room obtunded, pulseless and apneic; he was taken from the wheelchair to bed with the only history that he collapsed in bathroom in lobby while on his way to cardiology appt.  Family said he was feeling weak for the past 4 days.  CPR was immediately started by Intubation was accomplished quickly with a 7.5 Fr ET with good cord visualization; good end tidal CO2, and placed at 22 cm at the lip.  18 gauge IV established by nursing in left AC and epinephrine was given, CPR continued while the drug was circulated and a pulse check revealed fine V-Fib rhythm, a shock was delivered and faint pulse detected at the carotid but was quickly lost after less than 1 minute.  CPR was resumed, Amiodarone was given as this seemed a refractory V-Fib and in addition Bicarb was given and another round of Epi was given.  

At this point another rhythm check revealed fine V-Fib and another shock was delivered.  Bedside limited cardiac echo revealed no coordinated cardiac activity and no evidence of cardiac tamponade. CPR was again resumed. Right femoral central line was placed at this point.   VBG had returned and showed a K=8.2, I had Calcium gluconate given at this point and circulated the drug. There was no return of spontaneous circulation since the first time the patient was defibrillated.  

Patient’s wife was brought outside the trauma bay, he was intubated at this point and I explained to the wife and her son that about 15 minutes had gone by without cerebral perfusion.  I brought both the wife and her son into the resuscitation bay for the final couple minutes of the resuscitation.  I explained that if there was still no coordinated cardiac activity after 15 minutes that the patient would not recover neurologically.  There was no coordinated activity he would be pronounced at this point.  The rhythm was fine V-Fib refractory to defibrillation during the resuscitation.  This was not a medical examiner case and cause of death was acute coronary insufficiency.  Time of death was approximately 10:07am. 

Attestations:

I provided 30-74 minutes of critical care for this patient.

Answer: This is a complicated case that clearly meets the criterial for critical care in terms of the high probability of imminent or life threatening deterioration, but the minimum time thresholds are not met according to the documented arrival and pronouncement times (09:49 to 10:07), which only total 18 minutes. Even assuming adding some additional time for documentation and arranging care, there were multiple additional billable procedures performed that would have to be subtracted for the time allocated to the critical care clock.  

Even though there was a good caveat statement recorded with the chief complaint. “I was unable to obtain a clear HPI, ROS from the patient or review their PMH, FH, SH due to acuity of condition (patient not responsive),” there is sufficient documentation of history, physical exam and medial decision making to support a level five ED E/M service.

On the claim report 

• 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity)

• Append the 25 modifier to indicate it is separately reportable service than the procedures

• 92950 (Cardiopulmonary resuscitation [e.g., in cardiac arrest])

• 93308-26 (Echocardiography, transthoracic, real-time with image documentation [2D], includes M-mode recording, when performed, follow-up or limited study) with modifier 26 appended to show it is the professional interpretation only reported

• 31500 (Intubation, endotracheal, emergency procedure)

For the diagnosis report 

• ICD-9 427.5 (Cardiac arrest)
• ICD-10 I46.2 (Cardiac arrest due to underlying cardiac condition).