1

Evaluation and Management Evaluation and Management Coding Coding

for Emergency Medicinefor Emergency Medicinefor Emergency Medicinefor Emergency Medicine

ByBySarah Todt RN, CPC, CEDCSarah Todt RN, CPC, CEDC

11

Emergency DepartmentEmergency DepartmentEvaluation and Management CodesEvaluation and Management Codes

9928199281 9928199281 9928299282 9928399283 9928499284 9928599285

22

Critical Care 99291Critical Care 99291 +99292+99292

2

ED Evaluation & ManagementED Evaluation & Management CCodesodes

There are three key components that There are three key components that must be met to correctly assign anmust be met to correctly assign anmust be met to correctly assign an must be met to correctly assign an Evaluation and Management code:Evaluation and Management code:HistoryHistoryExamExamM di l D i i M kiM di l D i i M ki

33

Medical Decision MakingMedical Decision Making

CPT E/M Components OtherCPT E/M Components Other

Nature of the presenting problemNature of the presenting problem Nature of the presenting problemNature of the presenting problem 99283 vs. 99284 99283 vs. 99284

TimeTime Critical CareCritical Care

44

3

Medical decision making Medical decision making di t t th hi h t l l ddi t t th hi h t l l ddictates the highest level code dictates the highest level code

that can be chosen that can be chosen ––Proper documentation Proper documentation s pports o r choices pports o r choice

55

supports your choicesupports your choice

Medical Decision MakingMedical Decision Making

66

4

Levels of Medical Decision MakingLevels of Medical Decision Making

Straight ForwardStraight Forward Straight ForwardStraight Forward 9928199281

Low ComplexityLow Complexity 9928299282

Moderate ComplexityModerate Complexity

77

99283 and 9928499283 and 99284 High ComplexityHigh Complexity

9928599285

DOCUMENTATION OF MEDICAL DOCUMENTATION OF MEDICAL DECISION MAKINGDECISION MAKING

■■The number of possible diagnoses that must be The number of possible diagnoses that must be consideredconsideredconsideredconsidered

Chest pain patientChest pain patient Diff Dx chest pain: Angina, Diff Dx chest pain: Angina, PTxPTx, GERD, GERD Final Diagnosis GERDFinal Diagnosis GERD

The type The type of management optionsof management options

88

Rx drug management, IV fluids, Rx drug management, IV fluids, parenteralparenteralnarcoticsnarcotics

The amount and/or complexity of information The amount and/or complexity of information that must be obtained, reviewed, and analyzedthat must be obtained, reviewed, and analyzed Labs, XLabs, X--rays, EKGs, Medical records reviewedrays, EKGs, Medical records reviewed

5

Medical Decision Making Medical Decision Making Scoring SystemsScoring Systems

Most use the Marshfield Clinic Type Audit Tool toMost use the Marshfield Clinic Type Audit Tool to Most use the Marshfield Clinic Type Audit Tool to Most use the Marshfield Clinic Type Audit Tool to expand on the Documentation Guidelinesexpand on the Documentation Guidelines

Not an official part of the DGsNot an official part of the DGs Tool used to score the overall Medical Decision Tool used to score the overall Medical Decision

MakingMakingE al ates 3 componentsE al ates 3 components

99

Evaluates 3 components:Evaluates 3 components: Number of Diagnosis and Management OptionsNumber of Diagnosis and Management Options Amount and Complexity of DataAmount and Complexity of Data RiskRisk

Medical Decision Making:Medical Decision Making:Number of Diagnosis orNumber of Diagnosis or

Management OptionsManagement OptionsC ® d di i i h b dC ® d di i i h b dCPT® does not distinguish between new and CPT® does not distinguish between new and established patients in the EDestablished patients in the ED

New problem no additional Work upNew problem no additional Work upPatient seen and dischargedPatient seen and discharged

1010

Patient seen and discharged Patient seen and discharged

New problem with additional Work upNew problem with additional Work up Admit, Transfer, OR, ….Admit, Transfer, OR, ….

6

Medical Decision Making:Medical Decision Making:Amount or Complexity of DataAmount or Complexity of Data

Review and/order clinical lab test 1 pointReview and/order clinical lab test 1 point Review and/order clinical lab test 1 pointReview and/order clinical lab test 1 point Review and/order radiology test 1 pointReview and/order radiology test 1 point Review and/order medicine test 1 pointReview and/order medicine test 1 point Discussion of test results with performing physician 1 Discussion of test results with performing physician 1

pointpoint Decision to obtain old records and/or history from Decision to obtain old records and/or history from

someone other than the patient 1 pointsomeone other than the patient 1 point

1111

someone other than the patient 1 pointsomeone other than the patient 1 point Review and summarization of old records or obtaining Review and summarization of old records or obtaining

history from someone else or discussion of case with history from someone else or discussion of case with another health provider 2 pointsanother health provider 2 points

Independent visualization of image, tracing, or specimen Independent visualization of image, tracing, or specimen 2 points2 points

RiskRisk

The third part of the overall Medical decisionThe third part of the overall Medical decision The third part of the overall Medical decision The third part of the overall Medical decision MakingMaking

The Risk Table is an official part of CMS The Risk Table is an official part of CMS Documentation GuidelinesDocumentation Guidelines

Is scored independentlyIs scored independently Along with Management Options and Amount and Along with Management Options and Amount and

C l i f DC l i f D

1212

Complexity of DataComplexity of Data Highest level of risk in any category determines Highest level of risk in any category determines

the overall risk scorethe overall risk score

7

Risk TableRisk TableRisk of complications and/or Morbidity or Mortality Risk of complications and/or Morbidity or Mortality

Highest Level In Any Category PrevailsHighest Level In Any Category Prevails

99281 99292 99283 99284 99285MINIMAL LOW MODERATE HIGH

Suture removal (placed at other facility)

OTC med only; acute uncomplicated injury or illness

Rx management;Acute illness with systemic symptoms;Acute complicated injury;Exacerbation of chronic condition

Abrupt neuro change; Potential life threatening illness; Severe exacerbation of chronic illness; Medications requiring

i imonitoring; Parenteral controlled medications

1313

Scoring MDMScoring MDMMust Meet 2 out of 3Must Meet 2 out of 3

Mgt. Mgt. OptionsOptions

DataData RiskRisk Overall Overall MDMMDM

ED E/MED E/MSupportedSupportedpp SupportedSupported

-------------- 1 pt.1 pt. MinimalMinimal Straight Straight forwardforward

9928199281

-------------- 2 pts.2 pts. LowLow LowLowComplexityComplexity

9928299282

1414

New pt/ noNew pt/ noAdd’l w/uAdd’l w/u

3 pts.3 pts. ModerateModerate ModerateModerateComplexityComplexity

99283 and 99283 and 9928499284

New pt New pt with add’l with add’l w/uw/u

4 pts.4 pts. HighHigh HighHighComplexityComplexity

9928599285

8

CPT® Specific RulesCPT® Specific Rules

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Nature of The PresentingNature of The PresentingNature of The Presenting Nature of The Presenting ProblemProblem

1616

9

Nature of Presenting ProblemNature of Presenting Problem

9928199281 Usually, the presenting Usually, the presenting bl ( ) lf li it dbl ( ) lf li it d iiproblem(s) are self limited or problem(s) are self limited or minorminor

9928299282 Usually, the presenting Usually, the presenting problem(s) are of problem(s) are of lowlow to moderate to moderate

1717

severityseverity

9928399283 Usually, the presenting Usually, the presenting problem(s) are of problem(s) are of moderate severitymoderate severity

Nature of Presenting ProblemNature of Presenting Problem

9928499284 Usually, the presenting problem(s) Usually, the presenting problem(s) are of high severity, and are of high severity, and require urgent require urgent evaluationevaluation by the physician but do notby the physician but do notevaluationevaluation by the physician but do not by the physician but do not pose an immediate significant threat to life pose an immediate significant threat to life or physiologic function.or physiologic function.

9928599285 Usually, the presenting problem(s) Usually, the presenting problem(s) are ofare of high severityhigh severity and pose an immediateand pose an immediate

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are of are of high severityhigh severity and pose an immediate and pose an immediate significant threat to life of physiologic significant threat to life of physiologic function.function.

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Level III:Level III:General commentscomments

Moderate presenting problem but notModerate presenting problem but not Moderate presenting problem but not Moderate presenting problem but not requiring urgent evaluationrequiring urgent evaluation

Prescription Drug ManagementPrescription Drug Management Includes Rx meds given in ED Includes Rx meds given in ED

Eye drops, ear drops, Antibiotics, pain medsEye drops, ear drops, Antibiotics, pain meds

Limited diagnostic studiesLimited diagnostic studies Single XSingle X--rayray

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Level III:Level III:General commentsGeneral comments

Systemic symptomsSystemic symptoms Systemic symptomsSystemic symptoms Viral illnessViral illness

Mild exacerbation of chronic conditionMild exacerbation of chronic condition Recurrent conditionRecurrent condition

2020

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Level IV:Level IV:General CommentsGeneral Comments

Urgent Urgent TxTx of conditionof condition Multiple diagnostic studiesMultiple diagnostic studies Special studies alone (CT, MRI,US) Special studies alone (CT, MRI,US) ED Interventions:ED Interventions:

NebsNebs

2121

ParenteralParenteral medicationsmedications

Usually not admitted Usually not admitted

Level V:Level V:General CommentsGeneral Comments

Many AdmissionsMany Admissions

Frequently Involve:Frequently Involve: Prolonged services in EDProlonged services in ED Special Studies with other testsSpecial Studies with other tests--(CT/MRI/US)(CT/MRI/US)

2222

Multiple reassessmentsMultiple reassessments Interpretations of EKG or xInterpretations of EKG or x--raysrays Old record reviewOld record review Documented conversationsDocumented conversations

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HISTORYHISTORY

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HistoryHistory

The history portion of a patient’s chartThe history portion of a patient’s chartThe history portion of a patient s chartThe history portion of a patient s chartincludes some or all of the followingincludes some or all of the followingelements:elements: Chief complaint (CC)Chief complaint (CC) History of present illness (HPI)History of present illness (HPI)

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y p ( )y p ( ) Review of systems (ROS)Review of systems (ROS) Past, family and/or social historyPast, family and/or social history (PFS)(PFS)

13

LocationLocation--left sided chest pain, upper, lower, left sided chest pain, upper, lower,

History of Present IllnessHistory of Present Illness

posteriorposterior ContextContext ––while shoveling snow, while while shoveling snow, while

cutting a roll, during the football game, cutting a roll, during the football game, scratched by the catscratched by the catQ litQ lit hh h t ih t i th bbith bbi

2525

QualityQuality ––sharpsharp chest pain, chest pain, throbbingthrobbingheadache, headache, crampycrampy belly painbelly pain

TimingTiming –– worse at night, daily, constant, worse at night, daily, constant, frequentfrequent

History of Present IllnessHistory of Present Illness

SeveritySeverity ––moderate chest pain 6 out ofmoderate chest pain 6 out of SeveritySeverity ––moderate chest pain, 6 out of moderate chest pain, 6 out of 1010

DurationDuration--10 minutes, for a week10 minutes, for a week Modifying FactorsModifying Factors––worse with exertion, worse with exertion,

unrelieved by Tylenolunrelieved by Tylenol

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unrelieved by Tylenolunrelieved by Tylenol Associated Signs and SymptomsAssociated Signs and Symptoms--

diaphoresis, fever, vomitingdiaphoresis, fever, vomiting

14

History of Present IllnessHistory of Present Illness

HPI flushes out the chief complaint in HPI flushes out the chief complaint in t d t ilt d t ilgreater detailgreater detail

There are two types of HPI identified for There are two types of HPI identified for the purpose of codingthe purpose of coding A A briefbrief HPI consists of HPI consists of 11--3 3 elements elements

(99281(99281--99283)99283)

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An An extendedextended HPI consists of at least HPI consists of at least 44elementselements (99284(99284--99285)99285)

HPI Examples:HPI Examples:

BriefBrief-- 32 year old male with32 year old male with left shoulderleft shoulder BriefBrief 32 year old male with 32 year old male with left shoulder left shoulder injury, occurred injury, occurred 4 hours ago4 hours ago

ExtendedExtended--45 year old female with 45 year old female with left left sided, sided, sharpsharp chest pain for chest pain for 30 minutes30 minuteswith leftwith left arm numbness and diaphoresisarm numbness and diaphoresis

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with left with left arm numbness and diaphoresisarm numbness and diaphoresis. . The pain is The pain is worse with exertionworse with exertion

15

HPI Examples HPI Examples Multiple Modifying ElementsMultiple Modifying Elements

Child with Chief Complaint of fever:Child with Chief Complaint of fever:Child with Chief Complaint of fever:Child with Chief Complaint of fever:4 hours4 hours of fever, with of fever, with moderate vomitingmoderate vomiting, ,

diaphoresis that is worse at nightdiaphoresis that is worse at night, , right right lower quadrant abdominal painlower quadrant abdominal pain, , unrelieved unrelieved by Tylenolby Tylenol

2929

Review of Systems (ROS)Review of Systems (ROS)

An inventory of body systemsAn inventory of body systems An inventory of body systemsAn inventory of body systems “Patient’s positive responses and pertinent “Patient’s positive responses and pertinent

negatives should be documented”negatives should be documented” “For the remaining systems, a notation “For the remaining systems, a notation

indicating all other systems are negative isindicating all other systems are negative is

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indicating all other systems are negative is indicating all other systems are negative is permissible”permissible”

CMS 1995 Documentation GuidelinesCMS 1995 Documentation Guidelines

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Review of SystemsReview of Systems (14)(14)

Allergic/ImmunologicAllergic/Immunologic CardiovascularCardiovascular

GenitourinaryGenitourinary Hematologic/Lymph.Hematologic/Lymph.

Constitutional Constitutional Symptoms Symptoms

Ears, Nose, Mouth, Ears, Nose, Mouth, ThroatThroat

g / y pg / y p IntegumentaryIntegumentary MusculoskeletalMusculoskeletal NeurologicalNeurological PsychiatricPsychiatric

3131

EndocrineEndocrine EyeEye GastrointestinalGastrointestinal

PsychiatricPsychiatric RespiratoryRespiratory

Review of Systems (ROS)Review of Systems (ROS)

A A problemproblem pertinentpertinent ROS ROS addresses 1 addresses 1 pp ppsystemsystem (99282/99283)(99282/99283)

An An extendedextended ROS ROS addresses 2addresses 2--99 body body systems (99284)systems (99284)

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A A completecomplete ROS ROS addresses addresses at least at least 1010organ systems (99285)organ systems (99285)

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Past, Family, Social History (PFS)Past, Family, Social History (PFS)

Past HistoryPast History -- A review of the patient's past A review of the patient's past experiences with illnesses, injuries, treatmentsexperiences with illnesses, injuries, treatments, past , past hospitalizations, surgeries, medications, allergies,hospitalizations, surgeries, medications, allergies,hospitalizations, surgeries, medications, allergies, hospitalizations, surgeries, medications, allergies, immunizationsimmunizations

Family HistoryFamily History -- A review of medical events in the A review of medical events in the patient's family patient's family with regard to chronic illness, cause of with regard to chronic illness, cause of death or diseases related to the current compaintdeath or diseases related to the current compaint

3333

death, or diseases related to the current compaintdeath, or diseases related to the current compaint

Social HistorySocial History -- An age appropriate review of past and An age appropriate review of past and current activitiescurrent activities such as drug and alcohol use, living such as drug and alcohol use, living situation, and job historysituation, and job history

Past, Family, Social History (PFS)Past, Family, Social History (PFS)

There are two types of PFS There are two types of PFS in in emergency department codingemergency department codingemergency department coding.emergency department coding. A A pertinentpertinent PFS consists of any PFS consists of any 1 1

element from the PFSelement from the PFS (99281(99281--99284)99284)AA l tl t PFS i t fPFS i t f

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AA completecomplete PFS consists of one PFS consists of one element from element from 2 2 of the of the 3 3 PFS history PFS history areasareas for ED E/M codes (99285)for ED E/M codes (99285)

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History IssuesHistory Issues ROS and PFSH may be recorded by others ROS and PFSH may be recorded by others

The provider must reference the elementsThe provider must reference the elements ROS not as easy to obtain from NNsROS not as easy to obtain from NNs

No need to record things in more than one placeNo need to record things in more than one place ROS elements may be documented in the HPIROS elements may be documented in the HPI

A chief complaint will generally include at least one ROSA chief complaint will generally include at least one ROS Chest pain associated with nausea and vomiting Chest pain associated with nausea and vomiting

3535

HPI element for associated signs/HPI element for associated signs/sxssxs GI ROS elementGI ROS element

Same statement may not satisfy multiple subSame statement may not satisfy multiple sub--elements of elements of HPI or ROSHPI or ROS Chest pain since this morning can not be both timing and Chest pain since this morning can not be both timing and

durationduration

THE “EMERGENCY MEDICINE” CAVEATTHE “EMERGENCY MEDICINE” CAVEAT

“If the physician is unable to obtain a “If the physician is unable to obtain a history from the patient or other sourcehistory from the patient or other sourcehistory from the patient or other source, history from the patient or other source, the record should describe the patient’s the record should describe the patient’s condition or other circumstances which condition or other circumstances which precludes obtaining a history.”precludes obtaining a history.”

3636

CMS 1995 Documentation GuidelinesCMS 1995 Documentation Guidelines

19

CMS History CaveatCMS History Caveat

Documentation must include theDocumentation must include the Documentation must include the Documentation must include the reasonreason history is not obtainedhistory is not obtained NH patient with dementiaNH patient with dementia PostictalPostictal SevereSevere dyspneadyspnea (CHF or Asthma)(CHF or Asthma)

3737

Severe Severe dyspneadyspnea (CHF or Asthma)(CHF or Asthma)

ExamExam

3838

20

To determTo determinine the extent of an examination e the extent of an examination CPT recognizes the following 11 CPT recognizes the following 11 organ organ systemssystems::

1995 Guidelines for Physical Exam 1995 Guidelines for Physical Exam

systemssystems: : EyesEyes --PsychiatricPsychiatric CardiovascularCardiovascular --RespiratoryRespiratory GastrointestinalGastrointestinal --GenitourinaryGenitourinary MusculoskeletalMusculoskeletal --SkinSkin

3939

NeurologicNeurologic Hematologic/Lymphatic/ImmunologicHematologic/Lymphatic/Immunologic Ears, Nose, Mouth and ThroatEars, Nose, Mouth and Throat (CMS recognizes constitutional)(CMS recognizes constitutional)

1995 Documentation Guidelines 1995 Documentation Guidelines 7 Body Areas7 Body Areas

HeadHead--including faceincluding face HeadHead--including face including face NeckNeck ChestChest--including breast and axillaeincluding breast and axillae AbdomenAbdomen

Back including spineBack including spine

4040

Back including spineBack including spine Genitalia, groin, buttocksGenitalia, groin, buttocks Each extremityEach extremity

21

1995 Guidelines for Physical Exam1995 Guidelines for Physical Exam

Problem FocusedProblem Focused--1 Body System 1 Body System including affected areaincluding affected area (99281)(99281)

Expanded Problem FocusedExpanded Problem Focused -- a limited a limited examination of the affected body area or examination of the affected body area or organ system and related body area(s) ororgan system and related body area(s) or

4141

organ system and related body area(s) or organ system and related body area(s) or organ system(s)organ system(s) 22--4 Body systems including affected 4 Body systems including affected

areaarea (99282/99283)(99282/99283)

DetailedDetailed -- an extended examination of an extended examination of the affected body area(s) or organ the affected body area(s) or organ system(s) and any other symptomatic orsystem(s) and any other symptomatic or

1995 Guidelines for Physical Exam 1995 Guidelines for Physical Exam

system(s) and any other symptomatic or system(s) and any other symptomatic or related body area(s) or organ system(s)related body area(s) or organ system(s)

55--7 Body areas or systems 7 Body areas or systems including affected areaincluding affected area (99284)(99284)

ComprehensiveComprehensive -- a general multia general multi--systemsystem

4242

ComprehensiveComprehensive a general multia general multi system system examinationexamination

8 or more 8 or more organorgan systemssystems including including affected areaaffected area (99285)(99285)

22

Documentation Guidelines Documentation Guidelines Physical ExamPhysical Exam--Record FormatRecord Format

Checklists to indicate performance of any item Checklists to indicate performance of any item ok ok □□ Lungs CTABLungs CTAB

Brief statement or notation “negative” or Brief statement or notation “negative” or “normal” ok for normal findings “normal” ok for normal findings ENTENT--normalnormalSpecific abnormal and clinically relevantSpecific abnormal and clinically relevant

4343

Specific abnormal and clinically relevant Specific abnormal and clinically relevant negative must be documentednegative must be documented-- “abnormal” “abnormal” without elaboration insufficientwithout elaboration insufficientAbdomen soft, tender RLQ, BS poorAbdomen soft, tender RLQ, BS poor

Common Documentation E/M Common Documentation E/M Down Codes for Medicare recordsDown Codes for Medicare records

HPIHPI--need 4 HPI elements for 99285need 4 HPI elements for 99285 With 3 or less go down to 99283With 3 or less go down to 99283 With 3 or less go down to 99283With 3 or less go down to 99283

ROSROS--need 10 ROS for level 99285need 10 ROS for level 99285 If 2If 2--10 go down to 9928410 go down to 99284

Ph i l EPh i l E d 8 t f 99285d 8 t f 99285

4444

Physical ExamPhysical Exam--need 8 systems for 99285need 8 systems for 99285 If <8 go down to 99284If <8 go down to 99284

Past/Family/SocialPast/Family/Social-- need 2 for 99285need 2 for 99285 If just one go down to 99284If just one go down to 99284

23

99285 Acuity Caveat99285 Acuity Caveat 99285 ED visit 99285 ED visit for the evaluation and for the evaluation and

management of a patient, which requires these management of a patient, which requires these three key components three key components within the constraints within the constraints imposed by the urgency of the patient's clinicalimposed by the urgency of the patient's clinicalimposed by the urgency of the patient s clinical imposed by the urgency of the patient s clinical condition and/or mental statuscondition and/or mental status

Severe Severe DyspneaDyspnea -- COPD, Asthma PneumoniaCOPD, Asthma Pneumonia Unstable Vital SignsUnstable Vital Signs-- Trauma, SepsisTrauma, Sepsis Severe PainSevere Pain -- Long bone fractures openLong bone fractures open

4545

Severe Pain Severe Pain -- Long bone fractures, open Long bone fractures, open fracturesfractures

CPR/CPR/intubatedintubated Should state on chart: Hx/Exam limited by____Should state on chart: Hx/Exam limited by____

Documentation GuidelinesDocumentation Guidelines

HPIHPI ROSROS PFSHPFSH ExamExam Level of ServiceLevel of ServiceHPIHPI ROSROS PFSH PFSH ExamExam Level of ServiceLevel of Service

11 00 00 11 9928199281

11 11 00 22 9928299282

11 11 00 22 9928399283

4646

44 22 11 55 9928499284

44 1010 22 88 9928599285

24

2010 RVUs2010 RVUs

4747

Critical CareCritical Care

4848

25

Critical Care OverviewCritical Care Overview

Evaluation and Management (E/M) CodeEvaluation and Management (E/M) Code Evaluation and Management (E/M) CodeEvaluation and Management (E/M) Code Found in first section of CPT®Found in first section of CPT® Reported using 99291 Reported using 99291 Additional work reported with the Additional work reported with the

add on code +99292add on code +99292

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add on code +99292add on code +99292

Critical Care OverviewCritical Care Overview

Unlike other E/M codes no specific keyUnlike other E/M codes no specific key Unlike other E/M codes no specific key Unlike other E/M codes no specific key element requirementselement requirements History, Physical Exam, Medical Decision History, Physical Exam, Medical Decision

MakingMaking

No Specific HPI, ROS, Physical Exam No Specific HPI, ROS, Physical Exam

5050

documentation requirementsdocumentation requirements Time based codeTime based code Patient must meet certain clinical criteriaPatient must meet certain clinical criteria

26

Critical Care DefinitionCritical Care Definition

“A critical illness or injury acutely impairs “A critical illness or injury acutely impairs one or more vital organ systems such that one or more vital organ systems such that

there is a high probability of imminent or life there is a high probability of imminent or life threatening deterioration in the patient's threatening deterioration in the patient's

condition..”condition..”

5151

condition.. condition.. (AMA/CPT 2008)(AMA/CPT 2008)

Organ System FailureOrgan System Failure Central nervous Central nervous

system failuresystem failure Hepatic FailureHepatic Failure

EncephalopathyEncephalopathysystem failuresystem failure StrokeStroke

Circulatory failureCirculatory failure Acute MIAcute MI

ShockShock Severe traumaSevere trauma

EncephalopathyEncephalopathy CoagulopathyCoagulopathy

Metabolic failureMetabolic failure Toxic Ingestion (methanol)Toxic Ingestion (methanol) Severe AcidosisSevere Acidosis

Respiratory FailureRespiratory Failure

5252

Renal failureRenal failure New onsetNew onset HyperkalemiaHyperkalemia

p yp y PneumoniaPneumonia

27

Critical Care RequirementsCritical Care Requirements

Clinical Requirement of high probability ofClinical Requirement of high probability of Clinical Requirement of high probability of Clinical Requirement of high probability of deteriorationdeterioration

Time requirementTime requirement

5353

Minimum 30 minutes Minimum 30 minutes

Excludes separate proceduresExcludes separate procedures

“Full Attention “Full Attention And Physician Time”And Physician Time”

Time counted must be exclusively devoted toTime counted must be exclusively devoted to Time counted must be exclusively devoted to Time counted must be exclusively devoted to patientpatient

Does not have to be continuousDoes not have to be continuous Physician must document total time on chart Physician must document total time on chart Must document that time involved inMust document that time involved in separately separately

billable p oced es as not co ntedbillable p oced es as not co nted to a d CCto a d CC

5454

billable procedures was not counted billable procedures was not counted toward CC toward CC timetime

Attestation with check box or fill in the blank OKAttestation with check box or fill in the blank OK

28

Critical Care TimeCritical Care TimeWhat Counts?What Counts?

Bedside patient careBedside patient care Bedside patient careBedside patient care Reviewing ancillary studiesReviewing ancillary studies Discussions with:Discussions with:

Family, rescue, nursing, physicians as related Family, rescue, nursing, physicians as related to careto care

Ch t d t ti d l tiCh t d t ti d l ti

5555

Chart documentation and completionChart documentation and completion Bundled ProceduresBundled Procedures

CXRCXR

Critical Care Bundled ServicesCritical Care Bundled Services

C di O t tC di O t t TranscutTranscut PacingPacing Cardiac OutputCardiac Output

93561/9356293561/93562

CXRCXR 71010/71015/7102071010/71015/71020

Pulse Pulse OximetryOximetry

TranscutTranscut. Pacing. Pacing 9295392953

Ventilator Mgt.Ventilator Mgt. 9400294002--94004, 94660, 94004, 94660,

9466294662

Vascular AccessVascular Access

5656

94760/61/6294760/61/62

Computer DataComputer Data 9909099090

36000/36410/15/4036000/36410/15/40 3660036600

Gastric IntubationGastric Intubation 43752/9110543752/91105

29

Critical Care:Critical Care:“What is not included?”“What is not included?”

EndotrachealEndotracheal intubation 31500intubation 31500 EndotrachealEndotracheal intubation 31500intubation 31500 CPR 92950 (time must be subtracted)CPR 92950 (time must be subtracted) Triple Lumen Catheter insertion 36556Triple Lumen Catheter insertion 36556 TransvenousTransvenous pacer 92953pacer 92953

EKG interpretation 93010EKG interpretation 93010

5757

EKG interpretation 93010EKG interpretation 93010

Bill these separatelyBill these separately

Critical Care Time RequirementsCritical Care Time Requirements

Critical Care TimeCritical Care Time CodeCodeCritical Care TimeCritical Care Time CodeCode

<30 minutes<30 minutes Approp. E/M codeApprop. E/M code

3030--7474 9929199291

5858

7575--104104 99291, 9929299291, 99292

105105--134134 99291, 99292 X 299291, 99292 X 2

30

Clinical Conditions Consistent with Clinical Conditions Consistent with Critical Care Critical Care (1)(1)

l l d ll l d l Severely altered mental statusSeverely altered mental status Cardiac or respiratory arrestsCardiac or respiratory arrests Airway compromiseAirway compromise Need for immediate surgeryNeed for immediate surgery

TraumaTrauma

5959

TraumaTrauma Ruptured ectopicRuptured ectopic Perforated ViscousPerforated Viscous AAAAAA

May Not Qualify For Critical CareMay Not Qualify For Critical Care

Admission to Critical Care servicesAdmission to Critical Care services Admission to Critical Care services Admission to Critical Care services secondary to no other bed in hospital secondary to no other bed in hospital Tele BordersTele Borders Hospital Specific Rules such as:Hospital Specific Rules such as:

nebs Q 2 hours nebs Q 2 hours

6060

in otherwise stable patientsin otherwise stable patients

31

Critical Care:Critical Care:Other FactsOther Facts

“All other billable procedures not included“All other billable procedures not included All other billable procedures not included All other billable procedures not included in CC time”in CC time”

Requires 30 to 74 minutes for first hour of Requires 30 to 74 minutes for first hour of CCCC

Frequently feedbackFrequently feedback

6161

Frequently feedbackFrequently feedback

Teaching Physicians Teaching Physicians Critical CareCritical Care

Resident time does not countResident time does not count Resident time does not countResident time does not count TP personal time must be clearly TP personal time must be clearly

documenteddocumented Teaching time does not countTeaching time does not count Subtract time for separately billableSubtract time for separately billable

6262

Subtract time for separately billable Subtract time for separately billable proceduresprocedures

32

Critical Care and CPRCritical Care and CPR Critical reporting requires subtracting minutes Critical reporting requires subtracting minutes

spent performing separately billable proceduresspent performing separately billable proceduresspent performing separately billable proceduresspent performing separately billable procedures 92950 CPR is not a bundled service should be 92950 CPR is not a bundled service should be

reported separatelyreported separately Must subtract out amount of time spent Must subtract out amount of time spent

supervising CPRsupervising CPR

6363

QUESTIONS?QUESTIONS?

6464

33

Thank youThank you

Sarah Todt RN, CPC, CEDCSarah Todt RN, CPC, CEDCstodt@mrsiinc.comstodt@mrsiinc.comwww.mrsiinc.comwww.mrsiinc.com

6565