ED Coding and Reimbursement Alert

Certain documented phrases suggest the patient encounter qualifies for critical care.

A clearly documented critical care time statement helps clue coders into the fact that the physician thinks the encounter qualified for critical care. However, you also need to satisfy the requirement that the patient is critically ill or injured. That can be hard for a coder who is not clinically trained, but if certain phrases appear in the chart documentation, they suggest the high probability of imminent, life-threatening deterioration threshold that CPT® requires, says Rebecca Parker, MD, FACEP, president of Team Parker LLC, an ED coding and billing consulting company in Chicago, IL, and president of the American College of Emergency Physicians.

Check out these examples from common ED presentations that might qualify for critical care:

Chest pain

Consider Critical Care

EKG compatible with ischemia
Enzyme changes
Arrhythmias requiring treatment
IV beta blockers
Hypotension
Pain requiring ongoing IV NTG
Use of IV, heparin, lytics
Immediate disposition to cath lab or ICU

Probably not Critical Care

EKG normal and given ASA per protocol
Repeat EKGs, enzymes normal
SL or topical NTG only
Disposition home

Arrhythmias

Consider Critical Care

If symptomatic (e.g. syncope, altered mental status/neuro signs, chest pain, dyspnea; not simply palpitations) or significant co-morbidities such as ingestion
Treated with electricity, IV drips or vaso active drugs

Probably not Critical Care

PAT converted in field
Post spontaneous conversion in stable patient

Syncope

Consider Critical Care

Syncope plus a significant co-morbidity
Arrhythmias such as new onset atrial fibrillation
Lower or Upper GI bleed
Significant hypovolemia
Altered mental status or seizure
Pulmonary embolism

Probably not Critical Care

“Weak and dizzy”
No significant co-morbidity
Simple faint

Seizures

Consider Critical Care

Status
Complex febrile
Context of trauma, OD or ingestions
ETOH or drug withdrawal

Probably not Critical Care

Recurrent with noncompliant or sub-therapeutic meds

Stroke syndromes

Consider Critical Care

Abnormal vital signs requiring treatment
Any airway issues
Start or consider TPA
Rapid assessment and transfer for definitive treatment at a stroke center

Probably not Critical Care

Stable patient with completed stroke

Dyspnea

Consider Critical Care

CPAP
High flow oxygen, continuous nebs and ICU admit
Altered mental status
Impending respiratory failure documented
Intubation performed or considered
CHF (usually with pulmonary edema or severe dyspnea)

Probably not Critical Care

2-4 nebs or continuous nebs plus steroids and clear
Disposition home

Abdominal pain

Consider Critical Care

Immediate dispo to OR (eg AAA, perforated viscus)
Hemodynamic instability
ICU admit (bowel ischemia, sepsis)

Probably not Critical Care

Appy/diverticulitis: routine and admitted to floor
Perforated appy admitted to floor

Trauma

Consider Critical Care

Hemodynamic instability/abnormal vital signs
Possible cord injuries
Unresponsive/altered mental status
Procedures such as chest tube, intubation
Disposition to OR or transfer to Trauma Center

Probably not Critical Care

Mechanism alone in alert patient w/o complaints
Isolated extremity injuries w/o potential neurovascular compromise

Ingestions

Consider Critical Care

High lethality agent requiring intervention or close monitoring
Seizures, coma, arrhythmias, hypotension

Probably not Critical Care

Benign overdose with watchful waiting

Severe allergic reactions

Consider Critical Care

Stridor, wheezing. hypotension
SQ/IV epi or pressors

Probably not Critical Care

steroids and clears

Metabolic

Consider Critical Care

Most admitted DKA and/or other metabolic acidosis admitted to ICU
Hyperosmolar states (e.g. coma)

Probably not Critical Care

Mild DKA treated in ED and discharged

Sepsis

Consider Critical Care

Sepsis bundle management (central line, elevated lactate)
ICU admit
Immunocompromised patient
Transplants/cancer patients
Most infectious disease admits to ICU
Pneumonia, encephalitis, meningitis, endocarditis

Pediatric Dehydration

Consider Critical Care

Any shock-like state
Altered mental status

Environmental

Consider Critical Care

Hypothermia: either PLUS another problem or more than passive external re-warming
Lightning strike
CO with signs/symptoms and HBO treatment or emergent transfer