Critical Care or what?

Gemini18

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IMMEDIATE CAUSE OF DEATH:
1. Severe sepsis, gram-negative sepsis.
2. C.Diff colitis
3. Other contributing causes of death include hypokalemia, thrombocytopenia, severe protein calorie malnutrition, anemia and mycotic aneurysm.

Patient is found by neighbor in her care on 8/1/08, EMS is called. On arrival in the ED patient was found to have a temperature of 95.3 initially and then 101.3 later on. Pt was in ARF and hyponatremic. Pt was very hypoxic with sats at 77% on room air. Labs were abnormal with white count of 2.8 and chest x-ray finding in not acute disease. CT showed evidence of findings as discussed above. Pt was admitted with several altered mental status and sepsis.

Hospital Course:
1. Sepsis - started on IV Cipro. ID consulted
2. C. diff colitis - placed on Flagyl
3. Severe Shock - continued to be hypotensive afterwards. Despite initial treament, patient declined.

Pt expired at 19:40 on 8/3/08

Labs were done
Exam - General, Chest, Abd, CVS and Extremities

A/P
1. Sepsis. C. Diff Colitis
2. Hypotension
3. Hypokalemia
4. Thrombocytopenia
4. Mycotic aneurysm

No time documented, but it is coded as a critical care.
 
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MUST have time

You must have face-to-face time (30 minutes or more) spent providing critical care to the critically ill patient in order to code 99291-99292.

I see a critically ill patient. If there were time noted and some expansion on the cares given I'd agree with critical care code. But you've already mentioned there is no time noted.

We educate our physicians to document as follows: "I spent xx minutes providing critical care to this critically ill patient, exclusive of procedures."

If physician cannot (or will not) amend the record to note time spent in critical care, then I'd be inclined to code the discharge day management 99238 (again no time so you can't code 99239).

F Tessa Bartels, CPC, CEMC
 

ARCPC9491

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I definitely agree with Tessa. Documentation of time is a MUST for critical care, exclusive of procedures. I would be inclined to bill the discharge code, 99238. Check with the physician though, see if they'll amend the report with the time, then you'll have your critical care.
 

Gemini18

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Thank you

Thank you guys SO MUCH for your help -- I really appreciate this forum and all the INFORMATION and assistance I receive from each and everyone of you.
 
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