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I want to scream.

  1. #1
    Default I want to scream.
    Medical Coding Books
    So, I just HAVE to share this... I am pulling my hair out as I speak...

    Here's some *key documentation* from this note..

    "Pt alert, smiling & laughing, responsive, NAD" , "vitals signs are stable & unchanged since arrival" , "GCS score, 15" ---- I'll just stop there.

    & what in the world do you think was billed?

    Critical Care!!!!! no time documented, nothing. & I REALLY don't think that this patient is "critically ill" AHH!!

    I am struggling with these docs... I am constantly saying: "just because you are on the "trauma call" service doesn't necessarily mean every code ran & every patient that comes through that door is a critical care patient"

    I have showed them the regs on critical care, talked, talked, talked until I was blue in the face...doesn't seem to be working.

    Any other suggestions?!
    Last edited by ARCPC9491; 04-17-2009 at 08:48 AM.

  2. Default
    LOL this happens to me all the time. I take it back down to the dr and say, "Oh and BTW since you didn't document time for critical care, you will need to change it to subsequent care/H&P/ or whatever .... but not critical care. If the discharge time(more than 30 minutes 99239) isn't documented I just mark it out and change it to 99238. I do over 13 Dr's billing sheets and I can't babysit everyone of them.

    Good luck

  3. #3
    I'm not sure how the chain of command works at your office, but is there anyone else who "pulls more weight" than you do? Perhaps if someone of higher authority instructs this particular physician, maybe the info will stick. They should be listening to you in the first place, but it sounds like you've tried all logical solutions. I've noticed that some physicians will ignore what I say, but if my boss or the administrator mentions the problem, suddenly it gets fixed. That doesn't make it right, but sometimes we have to do whatever works.
    I can totally understand your frustration. At least it's Friday
    Carrie, BS, CPC

  4. #4
    Milwaukee WI
    Default I empathize...
    Oh, AR ... I whooped out loud to read your post.

    Same holds true on day 3 of ICU stay when "patient stable, ready to move to the floor when a bed is available" and they still want to bill critical care.

    S I G H ...

    In your case since there is no time, I'd just code it for the appropriate E/M (ER visit? outpatient consult? Initial Hospital visit?) and inform the doctor that you couldn't code critical care without
    1) clear indication that patient is critically ill and
    2) clear indication that the cares provided were critical care (I quote from 2009 CPT professional edition, page 18: 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.) AND
    3) At least 30 minutes spent in direct face-to-face critical care of patient (includes floor/unit time in hospital setting - EXCLUSIVE of procedures)

    Good luck!

    F Tessa Bartels, CPC, CEMC

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