Wiki critical care coding

[riverloverjen38@yahoo.com]

If a patient arrives to the ER in cardiac arrest due to drug overdose, CPR is done, patient is revived, should I code the appropriate ER E/M code or is it better to code critical care code?

 

[jimbo1231]

Tim?

Did the provider document 30 minutes or more of CC time? Were there other procedures? Clinically could be CC, but would need to know more.

Jim

 

[riverloverjen38@yahoo.com]

The patient came into the ER intibated and CPR in progress. The patient was revived and later found out that the patient had taken a bunch of pills. patient was put on a ventilator, a foley catheter was placed along with a NGT. The patient was eventually flown to a trauma center for further care. The patient was definitely in the ER for more than 30 minutes.

 

[Andrschery]

Critical Care is a time based code. The Physician must document the time spent in critical care of the patient excluding procedures. You can not assign critical care codes just because you can tell the patient was critical and the care was provided. The md must document his time spent providing the critical care to the patient. If not documented it wasn't done, assign an E/M level 99281-99285.

 

[jimbo1231]

I agree. But this could be a "teachable moment" for the provider. It does appear to be CC, and practice or hopsital are cheating themselves if time not documented. Might be worth going over elements that can be counted toward CC time with provider.

Jim