Wiki Critical Care Services

[AR2728]

Our hospitalists saw a patient for hypovolemic shock and acute renal failure, wanting to bill critical care and has documented an hour. Does this meet critieria for a critially ill patient? Below are scrubbed excerpts from the note:

HPI...female with a history of peptic ulcer disease, history of GI bleeding and known source of bleeding who had actually colonoscopy and EGD. They did not find anything done at ----Hospital and she had capsule endoscopy done on. They told them that the results for this test need around 10 days. She has a history of peptic ulcer disease but gets bleeding. She gets off Plavix by her cardiologist, Dr. _______ who saw her last week because of tachycardia and he cleared her for her surgery. The patient planned to have hip surgery because of osteoarthritis at ---- Hospital. The patient gets prepared for the GI work up by drinking GoLYTELY and she continued to have diarrhea. She went and saw Dr. ___ yesterday because of dizziness, lethargy and weakness and diarrhea. The area has been induced by GoLYTELY. It around 10 to 15 bowel movements a day. Watery, brown, no blood in it. The patient has some abdominal discomfort described as cramping. No fever or chills. When she arrived to the ER her blood pressure was in the 70s. Severely
dehydrated and she was tachycardic and she had high BUN and creatinine.
PLAN: Patient admitted to medical floor level four, very close observation. She is in acute care observation for her hypovolemic shock and acute renal failure. Hold all antihypertensive medication. Hold all nephrotoxic medication. Start her on IV fluids. She got bolus two liter of fluids in the ER. She was started on IV drip 150 cc. and hour with some potassium. She received one unit of blood all ready. Her hemoglobin has been improved from 7.3 to 8.8 currently. Her BUN and creatinine has been improved. Her sodium has gone up to 146. I will slow down on thefluids, switch her to ½ normal saline and I will restart some of home medication, will try to obtain those medications from the daughter because apparently they don't know the exact list of what she is taking and probably resume of some her medication that we held yesterday. I will put her aspirin
because she had recent stent but no Plavix. Continue on Misoprostol and Nexium and will initiate her diet.

 

[pjwalsh72]

I always ask the provider this question, "If you didn't do what you did when you did it, would the patient have been in imminent danger of losing life, limb or organ system?
If his answer is yes, then does the documentation describe what the provider did to stablize the patient? And lastly did he document how must time he spend providing critical care? Since Critical Care codes are time-based codes. He must doument how much time he spent providing critical care services. I didn't see where that was documented. So in my opinion this note does not qualify for critical care. Hope this helps