Wiki Critical Care

[elenafrankie]

I have a question related to critical care billing. We are an acute care hospital that provides emergency services. We had a patient that was seen in the ER, patient was intubated and placed on ventilator and prepped for transport. Unfortunately, there were no beds available and we had to keep the patient until one became available. The patient was in our facility for approximately 12.5 hours. Listed below is the physician information:

Acute hypoxic respiratory failure
Likely 2/2 oversedation/medication reaction at dentist
-Intubated with LMA and on vent with 100%fiO2 and PEEP 5, complicated by large
large pneumothorax now s/p left chest-tube with pigtail placement
-Continue to monitor tube and O2 status
-On midazolam drip for sedation

Can we bill critical care?

 

[thomas7331]

From the sounds of it the patient's condition was likely critical, but the documentation you've cited, by itself, is insufficient to support a critical care code as it lacks the required elements. Here's one good article about critical care that goes over this in more detail: https://www.aapc.com/blog/38346-critical-care-documentation-essentials/