Wiki Diagnosis Coding for Critical Care-Report Co-morbidities?

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jharo1733

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When coding for critical care services, it is appropriate to also code and bill for the patient's underlying co-morbid conditions although the physician is seeing a patient for respiratory distress/acidosis. Here is my example:

A patient was admitted 3 days ago and has colon ca with mets to the liver. The patient had a malignant bilary obstruction requiring stent placement. Today, he developed severe SOB and subsequent respiratory acidosis. I have been called emergently to evaluate the patient. Upon my arrival, the patient was noted to be in severe respiratory distress. I therefore intubated the patient and began vent management.

The physician also documents that the patient's colon ca and liver mets is being managed by GI and will be undergoing chemotherapy.

My question is that should the physician also document under the impression/plan the cancer diagnoses as well as bill for them? Or, since this is a critical care visit, is the physician only to document in the assessment/plan and only code for the critical care visit, i.e. respiratory distress, acidosis?
 
Good Question

Generally the approach to diagnosis coding in Emergency Medicine which is consistent with ICD-9 guidelines for outpatient is to code for the primary reason the patient came to the ED. Certainly respiratory distress justifies Critical Care (as long as your doc provided and documented 30 minutes of CC). But this is a very sick patient. I don't know if an argument can be made that there is a clinical relationship between the respitatory distress and the colon to liver cancer. But those conditions certainly say something about the overall condition of the patient that probably factored into the ED visit. I'd use the codes to paint a picture of a critically ill patient. Might prevent the need to send documentation to the payor after billing. But I respect other opinions on this case.

Jim S.
 
I agree with Jim in "using the codes to paint a picture"...the co-morbidities are factors contributing to the overall medical conditions.
 
I certainly agree with what you are saying. However, with that being said, I oftentimes see that the physicians who bill for critical care services only code the diagnoses for which they provided critical care. I am wondering if perhaps the reason for this is because they aren't the actual physician who is managing those co-morbid conditions. I was just curious if this is a common practice, and whether if they should also be reporting those co-morbidities, even if they don't actually manage or treat them. Obviously, the co-morbid conditions have a factor in the management and treatment of the patient, although the physician doesn't exactly state that part of their "thought process" in the documentation.

I am currently working in commercial risk adjustment. We are currently reviewing medical records to evaluate the them to see whether or not there are risk adjustable diagnoses that are documented but were not reported on claims. Extracting codes for risk adjustment is handled a bit differently than you would with E/M coding. One of our coding auditors was questioning why the critical care encounter did not include the cancer diagnoses, but only the respiratory distress/acidosis. Again, I want to make sure I have a firm grasp on whether or not critical care providers should in fact be reporting those co-morbidities even when they do not actively treat or manage those conditions or if they absolutely should be. Thank you.
 
Right

From a pure ICD-9 Guideline point of view coding of the co-morbidities might be questionable since the patient was reporting to the ED with symptoms at least not apparently related to the cancer. But for example if the physician noted that due to the matastatic cancer, patient was in a weakened state or immune system compromised, I think it would be reasonable to code the entire picture.
I've not been on the risk side; but wouldn't the entire picture of the patient weigh into the risk adjustment?

Jim
 
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