ED Coding and Reimbursement Alert

Code interactions with caregiver separately -- provided the physician directly discusses treatment options. Experts remind us that sometimes, you can count discussions with the patient's family, caregiver, or authorities toward overall critical care time. When you do, however, you'd better be sure it's wellnoted in the medical record, or you can expect payer scrutiny. Count Hx, Tx Time "Time spent obtaining history or discussing the patient's treatment options is not considered a separate service and should be included in the physician's total critical care time," relays Greer Contreras, CPC, senior director of coding for Marina Medical Billing Service Inc. in California. Example: A patient presents in apparent acute allergic reaction closing her airway; she is unable to speak or provide a history. After initial stabilization attempts start, the EP asks family members about known  allergies or exposure to substances that might have triggered the reaction. The conversation bears directly on the [...]