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Critical Care - I was wondering

  1. #1
    Default Critical Care - I was wondering
    Medical Coding Books
    I was wondering if anyone thought this visit is critical care? It is my understanding that if the pt is improving that it would be considered a subsequent visit. Although this pt was admitted a day previous to this report in critical care, from this report I do not see that he is still in a "critical" situation. Please, any advice would be appreciated.

    Pt improving clinically from Narcan drip, now stopped. Pt with nausea and chest discomfort as well.
    1)Methadone overdose--Apparently recreational, not suicide attempt, per pt. Cont IV fluids and oxygen. Psych consult pending. Labs look ok. Taper O2 as tolerated.
    2)Chest pain--Appears musculoskeletal, with increased pain with deep breath and movement. Will add Toradol for costocondral pain. Rib Xray pending--H & P notes "chest compressions" given at one point pre-hospital.
    3)Nausea-Cont PRN meds. IV fluids continue.
    4)Continue ICU level care at this point for monitoring. Follow Tele monitor for any changes.

    Methadone overdose
    Chest Pain

    Feels ok. Has significant amount of nausea, and chest pain with deep breath and movement. No other pain, no fevers, no urinary sx. No acute nursing concerns.

  2. #2
    I don't see time so critical care is out of the question regardless of the documentation.

    This does not look like critical care even if time had been documented.

    "Critical care is defined as a physician's (or physicians') direct delivery of medical care for a critically ill or critically injured patient. 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.
    Critical care involves high complexity decision making to assess, manipulate, and support vital system functions to treat single, or multiple, vital organ system failure; and/or to prevent further life threatening deterioration of the patient's condition."

    You are correct, this is just a subsequent care day.

    Laura, CPC, CEMC

  3. #3
    Smile Critical care
    I agree with Laura, seeing the word "improving" seems to show it is not as critical

  4. #4
    I would have to agree that it is not critical care as there is not documented time stating the physician's time was greater than 30 minutes and there is no organ system failure notated anywhere on the progress note. I would bill this as a subsequent visit.

  5. #5
    Thanks! I knew it!!! Just wanted to be double sure when I take it to the docs.

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