One of our biggest confusion and difficulty in coding critical care as well as other E/M's is the fact that, the physician may not include everything he did in the note, it may be documented elsewhere in the chart, and so, we don't know if we should be hunting for this information that can be in numerous places in the chart, or should it be in the report for that date of service? We were thinking that maybe we should be looking in other places in the chart for the emergent intervention for the critical care. I always went by the golden rule, if it is not documented it never happened, maybe that rule has changed. Anyway, we were also thinking about utilizing the prolonged E/M codes 99356 and 99357 along with the subsequent visit code if we have to down code it from a critical care code. Is that appropriate? We believe most of these critical care charges submitted by the doctors are really subsequents given the documentation.The following is a summary sample of a critical care note we usually bill for:
This is how the date of service is set up, another one of our concerns: Progress Note - Critical Care [18-Jun-2010 10:02]. Is that ok??
It is normally a five page note, with the first two pages consisting of vital signs. This one in particularly has notation regarding pain, stating, No pain behaviors present. Under Ventilator adjustment, he states, change; Rate decreased; Fi02 decreased. Don't know if that is relevant or helps or not. The patient is on a ventilator. The third page has the exam. The fourth page has the labs. Should we be looking at all of this to determine a critical code??? The fifth page what we really look at to determine the code, which is the assessment/plan:
Radiology: CXR: BLL infiltrates and effusions.
Prophylaxis: (Data referenced from "Progress Note - Critical Care" 03-May-2010 11:26)
GI: See meds.
DVT: See meds.
Assessment / Plan:
Neurologic / Psychiatric: Encephalopathy.
Cardiovascular: Circulatory collapse
Cardiomyopathy (EF 30%)
Equivocal troponin level
On pressors. Aggressive crystalloid and colloid support.
For trach aspirate.
Gastrointestinal / Nutrition: ? Acute abdominal catastrophe
Check hepatic profile, amylase/lipase For abd CT scan.
Renal / Metabolic: Renal failure: Acute on chronic (sCr 3)-? Dialyzed yesterday
Infectious Disease: Nosocomial sepsis vs. acute abdominal catastrophe
Empiric Azactam, Diflucan. Zosyn, Zyvox Arrange ID consultation.
Shock: See CARD.
Miscellaneous: Multi organ system failure (respiratory, hematologic, cardiovascular, renal) with profile of sepsis and/or abdominal catastrophe. Course reviewed and discussed with family and Dr. Prognosis poor.
Critical Care Time 90 minute(s) This excludes teaching time and all billable procedures. The above plan has been discussed with house staff, nursing and respiratory services
Signed 18-Jun-2010 10:12)
Authored: Vital Signs/ I&O, Respiratory Support, Physical Examination, Results, Prophylaxis, Assessment and Plan, Physician's Statement
Should we be looking at the meds also to determine the intervention, such as the ones above, IV antibiotics: Azactam, Diflucan, zosyn, etc…?
We are coding pulmonary critical care, the docs are intensivist as well.
We normally code all of the organ failures beginning with pulmonary organ failures :518.81, V46.11, 428.0, 584.9.
The documentation we have been reviewing is mainly dx driven without emergent intervention, and I know that that is not the only factor in determining a critical care code.
Would this be a critical care or subsequent??
This is how all of our critical care notes typically looks like. Please give us your two cents and any supporting documentation (specifically gearing toward emergent intervention, because they seem to have the required dx's documented and time)that we can show our docs would be greatly appreciated! Thank you very much!