Wiki Help with Critical Care Note

[TMB1965]

There was a patient on acute stroke alert, and was seen by the Neurologists to evaluate the patient. While the patient was in the scanner for a CTA of head and neck her neurological examination remarkably improved. She was alert, fluent and following commands, moved all 4 extremities, and had no sensory deficits.

The provider documented Acute Stroke Response. Suspect patient had transient acute encephalopathy secondary to metabolic imbalance precipitated by GIB in the setting of chronic renal failure/hemodialysis. He recommended MRI w/o contrast once patient is stabilize from GIB perspective

He documented critical care time 39 minutes.

Can I code this as a critical care 99291, and also what diagnosis would I use?
I don't see anything for acute stroke alert/response

Any suggestions would be very appreciative!

 

[talton0206]

From the section guidelines: "Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient's condition. Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure."

Although this patient is obviously seriously ill, without additional information, I don't think this is sufficient documentation of critical care. Just the word "transient" indicates that the patient didn't have "A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition."

What is GIB?

 

[TMB1965]

That is what I had originally thought too! I always like to get a second opinion if I'm unsure, so thank you! GIB stands for Gastrointestinal Bleeding.