1. Jason Adler, MD, FACEP, FAAEM
A Clinical Approach to Critical Care Coding- Rapid Fire Pearls You’ve Got to Know
Jason Adler, MD, FACEP, FAAEM
Case presentation –cardiomyopathy example then the tPA. Highlight message- pts are sicker than ever, we are providing cc services, and its good practice to align the service rendered with the coding/documentation.

2. National Trends Volumes steady Acuity is increasing
Older and medically complex
Mental health and chemical abuse
Highest injury rates > 75 yo
* source EDBMA

3. 8 years of Aetna data, 20M pts
Low acuity visits to the ED < 36%
Retail clinics >214%
Urgent care clinics >119%

4. Increasing Acuity Nationally

5. Maryland Vs National (Medicare)

6. CMS & CPT Definitions
An illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patients condition… …the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration of the patients condition.
Any time you have a pt…

7. A Clinical Approach Is at least one organ system acutely impaired?
Is there a high probability of imminent clinical deterioration?
Did the treating provider do anything to prevent that deterioration?
If the answers to the above are yes, then were the time requirements met?
Chest tube for ptx. Benadryl OD. Self inflicted knife wound.

8. The Time Piece Time-based code Can be included in time measurement
30-74 min, ,
Can be included in time measurement
At the Bedside
Immediately Available to the Patient
Ordering and reviewing diagnostic tests
Tx discussions with RN/EMT/Family/Consultants
Cumulative, not consecutive
Novitas is getting fussy. 1st code is broad

9. The Time Piece Also included -Bundled Procedures
NGT, Xray, ventilator management, Pulse Ox, ABG
The total time needs to be exclusive of…
Unbundled Procedures
TLC, lac repair, chest tube, CPR, Intubation
CC clock stops and starts after the procedure

10. What Qualifies for CC? Mimic the clinical encounter Vital signs
Interventions
Medications
Procedures
Diagnoses
Disposition
Here are our 5 checkpoints.

11. Vital Signs Suggestive of CC
Hypotension
Hypoxia
Hypothermia
Tachy/bradycardia
Jump off your chair

12. Medications Suggestive of CC
Anticoagulation-Lovenox, Heparin, Integrillin
Allergy/Asthma-Epi, Terbutaline, Magnesium
Antiarrhythmic-Adenosine, Diltiazem, Amio
Antidotes-Narcan, Glu, Bicarb, Charcoal
Blood Products- pRBC, Platelets, FFP, Vit K
Pressors- Levo, Dopa, Epi
Chemical Restraints – Antipsychotic/Benadryl/ Ativan
Most drips – Dextrose, Insulin, Protonix, Diltiazem

13. Procedures Suggestive of CC
Cardioversion
BiPAP/CPAP
Bag valve mask
Central line
Intubation
Chest tube
CPR*
If EP does elective cardioversion in the ED,

14. Diagnoses Suggestive of CC
Unstable VS
Hypotension, hypoxia
Acute coronary syndrome
Anticoagulation, to lab, transfer
Arrhythmia with IV intervention +/- electricity
SVT, VT/VF, Afib with RVR
Congestive heart failure
BiPAP, Ntg gtt, hypoxia, resp distress
Ego

15. Diagnoses Suggestive of CC
Respiratory Distress
Acute pulmonary edema
+ Epi – RSV, Croup, asthma, allergy
Pulmonary Embolism
Severe asthma
Epi, BiPAP, continuous nebs
GI bleed
Unstable VS, blood products, to endoscopy

16. Diagnoses Suggestive of CC
Intracerebral hemorrhage
Acute stroke – activation +/- tPA
DKA
Hyperkalemia with EKG changes, Calcium
Severe sepsis, septic shock
Overdose, EtOH withdraw
Psychiatric emergencies- Agitated Delirium

17. Disposition Suggestive of CC
Most Transfers to specialty center
PICU, burn, trauma, optho
Most ICU admissions
Some admissions
Step-down, telemetry units
Some discharges
*CPT Assistant, 7/02

18. Best Practices Specific number of minutes (not range)
Medical necessity
Space between exam and diagnosis
Progress notes
Serial assessments
Attestation
I spent approximately 35 minutes of critical care time to assess and manage the pts respiratory distress, with a high probability of imminent deterioration, including BiPAP and ntg drip, and frequent reassessments. This time is excluding procedure time.

19. FAQ
Can you count time when the pt is not in the dept? (EMS box call, post ED STEMI)
Can CPR and CC be billed for the same pt?
Can APPs claim CC?
No, not considered to be “immediately available”
Only if you meet time requirements beyond CPR time
Yes. Need to meet time requirements independently (can’t add time with supervising MD)

20. Final Thoughts
We are providing more critical care today than in years past
Critical care is a useful code when aligned with the services rendered