(Based on Presenting Problem) Joe Barton, MD, MHMS Oct 30, 2012

Transcription

1 (Based on Presenting Problem) Joe Barton, MD, MHMS Oct 30, 2012

2 Review specific critical care clinical presentations Outline which scenarios may NOT be appropriate for CC time Identify documentation and coding requirements Explore difference between and CC

3 Ask yourself two questions: Was the patient admitted (based on medical necessity) to ICU or taken immediately to the OR? If yes: strongly consider CC If no: is it really CC? If no (and you think it is CC): write a Medical Necessity note Will the patient die or deteriorate (quickly) if I don t do something (quickly)? If yes: document CC If no: is it really CC? If no (and you think it is CC): write a Medical Necessity note

4 CPT: CC is the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient s condition. CMS: CC involves high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient s condition.

5 Must be audit defensible Outside of Medicare/Medicaid, CPT rules may be slightly less stringent Definitions may sound the same, but might be very different! Medicare rule will almost always trump CPT

6 Considerable overlap and indistinct border between and CPT descriptors examples tend to suggest a high risk presentation MVA and symptoms compatible with intraabdominal and extremity injuries examples consistent with high risk presentation PLUS actual positive finding Auto vs ped with liver lac, pulmonary contusion

7 Requires 3 key components Within the constraints imposed by the urgency of the patient's clinical condition and/or mental status A comprehensive history A comprehensive examination Medical decision making of high complexity *High Risk* High severity presenting problem(s) Poses an immediate, significant threat to life or physiologic function.

8 Complicated overdose requiring aggressive management to prevent side effects from the ingested materials New onset of rapid heart rate requiring IV drugs Active, upper gastrointestinal bleeding Patient who arrives immobilized after an MVA with symptoms compatible with intra-abdominal injuries or multiple extremity injuries

9 Acute onset of chest pain compatible with classic symptoms of cardiac ischemia and/or pulmonary embolus Sudden onset of "the worst headache of life," and complains of a stiff neck, nausea, and inability to concentrate New onset of a cerebral vascular accident Acute febrile illness in an adult, associated with shortness of breath and an altered level of alertness

10 65-year-old male with septic shock following relief of ureteral obstruction caused by a stone 5-year-old with acute respiratory failure from asthma 45-year-old who sustained a liver laceration, cerebral hematoma, flailed chest, and pulmonary contusion after being struck by an automobile 65-year-old female who, following a hysterectomy, suffered a cardiac arrest associated with a pulmonary embolus 6-month-old with hypovolemic shock secondary to diarrhea and dehydration 3-year-old with respiratory failure secondary to pneumocystis carinii pneumonia

11 At the bedside or in the ED and immediately available to patient Requires MD s full attention, you cannot provide services to any other patient during that period of time May be aggregated, doesn t need to be continuous

12 At the bedside or in the ED and immediately available to patient Requires MD s full attention, you cannot provide services to any other patient during that period of time May be aggregated, doesn t need to be continuous Time spent in the box reviewing test results or imaging studies counts Discussing the critically ill patient's care with other medical staff counts CPT says yes to documentation, CMS says no

13 What about CMS and CPT description of immediately available when patient is in the cath lab or the OR and you re in the ED? Does documenting the record, speaking with family, or other non-bedside activity count when the patient is not in the ED?

14 The 25 minute door to cath lab patient: maybe Pre-hospital cath activation: probably not (controversial) CMS: Concurrent critical care services provided by each physician must be medically necessary and not provided during the same instance of time CPT: Only one physician/provider may report services for a given hour of critical care, even if more than one physician/provider has rendered critical care to the patient

15 Time spent speaking with family members or surrogate decision-makers counts if The patient is unable or incompetent to participate in giving history and/or making medically necessary treatment decisions There is a necessity to have the discussion There is a summary in the medical record that supports this medical necessity

16 Time spent speaking with family members or surrogate decision-makers counts if The patient is unable or incompetent to participate in giving history and/or making medically necessary treatment decisions There is a necessity to have the discussion There is a summary in the medical record that supports this medical necessity

17 Time that does not count Teaching time at the bedside Resident time alone at the bedside Otherwise, the medical review criteria are the same for the teaching physician as for all physicians Documentation must support all CC criteria

18 Time that does not count Teaching time at the bedside Resident time alone at the bedside Otherwise, the medical review criteria are the same for the teaching physician as for all physicians Documentation must support all CC criteria

19 Accurate time statement always required (avoid about or approximately) Document elements or acuity caveat These visits potentially can be down-coded to ED course should support high complexity MDM and establish medical necessity Document serial assessments and your decision making that involves the organ system at risk Document the critical lab, imaging, other study and/or EKG findings and their significance

20 Include diagnostic and therapeutic interventions performed and/or considered with the why, especially if you re performing the intervention Goal is to impart on paper the likelihood of life-threatening deterioration if you didn t do something on arrival or if you didn t intervene on a study result

21 Count towards CC time Interpretation of cardiac output measures Chest x-ray interpretation Blood draws, blood gases, and lab data ECGs Gastric intubation Pulse oximetry Temporary transcutaneous pacing Ventilator management Vascular access procedures (outside of central lines)

22 Separately billed Wound repair Intubation Chest tubes Central lines CPR (which is bundled, in and of itself )

23 Patient presents with chest pain and has a service provided While waiting for a bed, he has an episode of hypotension and run of ventricular tachycardia CPT: May report 9928x plus by same physician on same calendar day CMS: if critical care services are required upon arrival into the emergency department, only critical care codes may be reported

24 Patient presents with chest pain and has a service provided While waiting for a bed, he has an episode of hypotension and run of ventricular tachycardia CPT: May report 9928x plus by same physician on same calendar day CMS: if critical care services are required upon arrival into the emergency department, only critical care codes may be reported

25 Disposition suggesting CC should be considered: ICU admit (maybe telemetry) Direct to OR Death in the ED Disposition suggesting this is likely not CC: Floor admit Discharged home Documentation suggesting may not be CC NAD, Normal VS, Resting comfortably look at the nursing notes!

26 Minimally documented and/or benign ED course that does not support medical necessity Psych (generally) High risk presentation with subsequent r/o of critical illness/injury Urgent call and arrival of specialist is not CC unless necessary time portion of workup was initiated and treated by you Abnormal lab values alone do not support CC unless MDM reflects high complexity MDM initiation of life-saving assessment/treatment or prevention of a quick deterioration This is when your Medical Necessity statement is actually necessary, but our billers like to see it on all CC charts.

27 Minimally documented and/or benign ED course that does not support medical necessity Psych (generally) High risk presentation with subsequent r/o of critical illness/injury Urgent call and arrival of specialist is not CC unless necessary time portion of workup was initiated and treated by you Abnormal lab values alone do not support CC unless MDM reflects high complexity MDM initiation of life-saving assessment/treatment or prevention of a quick deterioration This is when your Medical Necessity statement is actually necessary, but our billers like to see it on all CC charts.

28 Consider CC EKG compatible with ischemia with enzyme changes Arrhythmias requiring treatment Hypotension Pain requiring ongoing IV NTG Use of IV heparin, lytics Immediate dispo to cath lab or ICU Probably not CC EKG normal and given ASA per protocol Repeat EKG, enzymes normal SL or topical NTG only (not given parenterally = less risk) Dispo home

29 Consider CC If symptomatic (eg syncope, altered mental status/ neuro signs, chest pain, dyspnea; not simply palpitations) With significant co-morbidities such as ingestion Treated with electricity, IV drips or multiple doses of drugs Probably not CC PAT converted in field Spontaneous conversion in stable patient Asymptomatic AF with single bolus of meds

30 Consider CC Hypertensive emergency end organ(s) affected (brain, heart, lungs, kidney) Treatment ongoing, with ICU admit Probably not CC Hypertensive urgency Incidental finding unrelated to main problem May get PO or IV Rx, but floor admit or discharged

31 Consider CC Syncope plus a significant co-morbidity Arrhythmias (see prior slide!) Lower or UGI bleed Significant hypovolemia Altered mental status or seizure Pulmonary embolism ICU admit Probably not CC Weak and dizzy No significant co-morbidity Simple faint

32 Consider CC Status epilepticus Complex febrile Context of trauma, OD or ingestions ETOH or drug withdrawal Probably not CC Recurrent Noncompliant Sub-therapeutic meds

33 Consider CC Abnormal vital signs requiring treatment Any airway issues Start/consider TPA Rapid assessment and transfer for definitive treatment at a stroke center Probably not CC Stable patient with completed stroke

34 Consider CC CPAP High flow oxygen, continuous nebs and ICU admit Altered mental status Impending respiratory failure documented Intubation performed or considered CHF with significant worsening of pulmonary edema or severe dyspnea Probably not CC 2-4 nebs or continuous nebs plus steroids and pt improves rapidly/clears Dispo to floor or home

35 Consider CC Immediate dispo to OR (AAA, perforated viscus) Hemodynamic instability ICU admit (bowel ischemia, sepsis) Probably not CC Appy/diverticulitis: routine and admitted to floor Perforated appy or diverticulitis initially admitted to floor

36 Consider CC Hemodynamic instability/abnormal VS Possible cord injuries Unresponsive/altered Procedures such as chest tube, intubation Dispo to OR or transfer to Trauma Center Probably not CC Low mechanism in alert patient w/o complaints Isolated extremity injuries w/o neurovascular compromise

37 Consider CC High lethality agent requiring intervention or close monitoring Seizures, coma, arrhythmias, hypotension Probably not CC Benign overdose with watchful waiting

38 Consider CC Stridor, wheezing. hypotension IV epi or pressors Probably not CC IM epi and/or IV steroids and clears

39 Consider CC Most admitted DKA and/or other metabolic acidosis admitted to ICU Hyperosmolar states (eg coma) Probably not CC Mild DKA treated in ED and sent home

40 Consider CC Abnormal EKG Symptomatic (eg confusion, muscle weakness) Requires IV treatment with active monitoring (severe hypokalemia) Emergent dialysis required Acute renal failure with ongoing management (ongoing fluids, bicarb drip)

41 Consider CC Sepsis bundle management (central line, elevated lactate) ICU admit Immunocompromised patient Transplants/cancer patients

42 Consider CC Any shock-like state Altered mental status

43 Consider CC Hypothermia: either PLUS another problem or more intervention than passive external rewarming Lightning strike CO with signs/symptoms and HBO treatment or emergent transfer

44 Consider CC Delirium or organic cause identified plus ICU admit Probably not CC Agitation due purely to psych issue

45 Always document to support Level 5 billing Accurately document time Write a medical necessity statement if you think it s CC

46 Questions?