Wiki Critical Care - how to bill this

[midnightsun1369]

how to bill this:

2 docs, same office, same specialty see's pt for cc in hospital setting.

doc 1 see's pt on floor in AM for 60 minutes (99291 1 unit) and states pt needs to be transferred to unit.

doc 2 see's pt in unit that night for 40 minutes (99291 1 unit).

Question is: does this get billed individually for each doc? if so does 25 modifier get added?
or
does this get billed under one doc with total time for the day?

Thanks for your help.

 

[mitchellde]

Just seeing the patient and transferring them to ICU is not enough for critical care, and seeing the payient in he the ICU does not automatically qualify for critical cre. The note written detailing the activity involved in the encounter is what qualifies. Without knowing what was done and documented I cannot say how it should or can be billed. However it is rare that you will have the components needed for critical care once the patient is already in the ICU .

 

[BenCrocker]

Oh, good question, I'm interested as well.

 

[midnightsun1369]

I believe both notes qualify for CC. I'm just not sure how to bill it.

doc 1 states:
4/16/2015 11:00 AM
Patient seen, examined and discussed with PA. The patient had been admitted the night before from Owosso and developed worsening respiratory failure. He was transferred on what sounds like a high flow system. Placed on NRB here initially and then BiPAP. When I evaluated the patient he was on high flow oxygen. His saturations with 40 L flow and 100% oxygen were only 86%. I had a very lengthy discussion with his wife at the bedside about his respiratory failure and that he will more than likely require intubation. She states that if there is some ay to get the patient better that she would like for him to be intubated. He does have abnormalities on his CXR, really needs repeat CT scan. Apparently history of pulmonary fibrosis. There was mention of lung mass, will defer to new CT scan. I discussed the case with the hospitalist, Dr. Obrien and the ICU resident. Will transfer to the ICU.

The patient has a high probability of sudden, clinically significant deterioration, which requires the highest level of physician preparedness to intervene urgently. I managed/supervised life or organ supporting interventions that required frequent physician assessment. I devoted my full attention to the direct care of this patient for the period of time indicated below. Time spent with family or surrogate(s) is indicated only if the patient was incapable of providing the necessary information or participating in medical decision making. Time devoted to teaching and any procedures I billed separately is not included. Total critical care time was 60 minutes.

Acute on chronic respiratory failure
Pt appeared to be in distress and declining will transfer to ICU, may need to be intubated.

doc 2 states:
Patient seen and examined with the resident on rounds. I agree with the history, physical, assessment and plan with the below noted modifications. Patient seen earlier by pulmonary service at the LTAC for worsening hypoxemia. Recently transferred over from Owosso. Had been hospitalized there for about a week and treated with supplemental oxygen and antibiotic therapy. Apparently had imaging over there including a CT scan which was unavailable for review. Earlier today was noted to be more hypoxemic and obtunded. Stat arterial blood gas demonstrated worsening respiratory acidosis/hypercapnia. On physical examination he will arouse easily of present is conversant and follows commands. Currently on BiPAP 10/5 cm of water. Chest x-ray reviewed from earlier this morning. Demonstrates significant alveolar opacities throughout the left lung more so in the left lower lobe. The right lung field is relatively clear although has low lung volumes.

Assessment:
Acute on chronic hypercapnic hypoxic respiratory failure requiring noninvasive positive pressure ventilation
Acute encephalopathy
Consolidation throughout left lung, pneumonia versus mass
COPD/pulmonary fibrosis by history
Inflammatory bowel disease/Crohn's disease, on biologic therapy

Plan:

PAP increased to 15 cm of water and EPAP increased to 8-10 cm of water
Repeat ABG in 2 hours
Continue IV antibiotics
CT of the chest when clinically stable
Aspiration precautions
Urinary antigens for strep, Legionella histoplasmosis
Fungal precipitins

The patient has a high probability of sudden, clinically significant deterioration, which requires the highest level of physician preparedness to intervene urgently. I managed/supervised life or organ supporting interventions that required frequent physician assessment. I devoted my full attention to the direct care of this patient for the period of time indicated below. Time spent with family or surrogate(s) is indicated only if the patient was incapable of providing the necessary information or participating in medical decision making. Time devoted to teaching and any procedures I billed separately is not included.
Total critical care time was 40 minutes 1545-1625

 

[mitchellde]

Two providers same specialty same practice is treated as one provider. If you read the instructions for critical care in the CPT book it will tell you the time spent does not need to be continuous. You combine the times together and bill as one encounter. So you have 100 minutes total. for 75-104 minutes you bill
99291
99292
While I am not of the mind that the assessment of this patient represents critical care coding that is how it would be billed. I am drawn to the exact same paragraph in both notes which tells me this is a cloned paragraph. I just do not get the feel for this as critical care.

 

[midnightsun1369]

Thank you for your reply. I did know that the time did not have to be continuous, but was unsure when 2 providers attended the pt at separate times.

are you speaking of this paragraph as being cloned?

The patient has a high probability of sudden, clinically significant deterioration, which requires the highest level of physician preparedness to intervene urgently. I managed/supervised life or organ supporting interventions that required frequent physician assessment. I devoted my full attention to the direct care of this patient for the period of time indicated below. Time spent with family or surrogate(s) is indicated only if the patient was incapable of providing the necessary information or participating in medical decision making. Time devoted to teaching and any procedures I billed separately is not included. Total critical care time was 60 minutes

This is the "generic" statement that they add to every cc note.

 

[BenCrocker]

Looks like a "canned" response to me.

 

[mitchellde]

it is a cloned statement and should not be used for the decision for critical care codes. I am looking at the current assessment of the patient. The provider mainly references observations from other providers. I do not see a current examination of the patient except that he arouses easily and is conversion. This does not suggest that this is critical care at this point. Maybe I just am not reading it in the right light. I see a moderately Ill patient but I am not getting critical care from these notes.

 

[BenCrocker]

I agree, it just looks like a very sick patient being checked on in rounds. Nothing more than that.