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Thread: Still Critical Care?

  1. #1
    Join Date
    Apr 2007

    Default Still Critical Care?

    AAPC: Back to School
    If I have a patient who is on vent depen. for six days can we still bill day six as critical care if they are stable? Our hospitalists have been coding their own work and the first five days of this pt's visit was coded critical care even after stablized due to being on the vent. Now I have a diff dr on day 6 and she is only billing a subsequent. Who is correct?

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default Stable

    A person may be critically ill and still stable (because they are not getting worse).

    So both physician's may be "correct." Impossible to really tell without seeing all the actual notes.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Join Date
    Apr 2007

    Default Notes for both DOS

    This note was coded 99233:
    Vent Dependent Resp Failure - DAY # 6
    CAP - Left lower lobe
    Bilateral cavitary lesions in the upper lobe
    Hypotension requiring pressors
    Oral candidiasis

    vent management per pulmonary
    antibiotics per ID
    Code level 3 - treat hypotension and arrhythmias
    Family meeting 8/5/09 - with no plans for trach
    DC TPN - TFs are at goal rate

    Pt remains in the ICU on the Vent
    TPN and TFs cont

    Chart reviewed
    Case was discussed with multiple consultants
    Presently hypotensive - pressors to be restarted.
    Case was discussed with POA by pulmonary
    Family is OK with treating hypotension and arrhythmias
    Plt count is low - but stable
    Aristra was started 8/2/09

    Vital Signs
    Date Time Temp Pulse Resp B/P Pulse Ox O2 Delivery FiO2
    8/3/09 06:00 112
    8/3/09 06:00 25 96/75 99 Mechanical Ventilator 30
    8/3/09 04:00 98.0

    Lungs: scattered ronchi and wheezes
    Heart: RSR
    EXt: thin, no edema

    Multivitamins 10 35 mls/hr 8/3/09 0015
    ml/Chromium/ Q24H/IV 8/3/09 0400
    Zinc 1 ml/
    Electrolytes 20
    Phosphate 15 mm/
    Chloride 20 meq/
    Magnesium Sulfate
    12 meq/Calcium
    Gluconate 4.65
    Acetate 15 meq/
    Potassium Acetate
    10 meq/Thiamine
    HCl 50 mg/Amino

    Feeding Tube Type Dobhoff 8/3/09 0400
    Tube Feeding/Supplement Type Jevity 1 8/3/09 0400
    Tube Feeding Rate 45 ml/hr 8/3/09 0400

    Pre-admission Medications:
    Spironolactone 100 mg daily.
    prednisone 10 mg daily.
    Flomax 0.4 mg daily.

    Darvon one tablet q.4h p.r.n. for pain.

    This note from previous day was coded 99291:

    1) Vent Dependent Resp Failure--Remains intubated. CXR pending--may need bronch if worsening or if no improvement. Per family, continue vent, but Level 3 code if status worsens.
    2) Cavitary Pneumonia and TB--Cont meds per pulm and ID. AFB PCR pending. HIV resent--pending. Pt with temp 100.0 overnight--will d/w pulm and ID if diagnostic thoracentesis would be of any benefit.
    3)Cardiac--Hypotension and CHF--Contuinue careful fluid balance. Cardiology and pulm following. Off pressors at present, though pressures lower today than yesterday.
    4)Neuro--Neuro following--likely sx due to hypoxia episode and low perfusion. Weaker on Right side. Made eye contact and making purposeful movements this AM when diprovan off.
    5)Thrombocytopenia--Check HIT panel. For now continue Lovenox.
    6)Anemia-Now at 9.1. Monitor closely.
    7) Malnutrition--Continue doboff feeding and trying to wean off tpn
    9)DVT proph

    Vent Dependent Resp Failure
    Left lower lobe community acquired pneumonia
    Bilateral cavitary lesions in the upper lobe
    Hypotension requiring pressors
    Oral candidiasis

    Pt remains on vent. When Diprovan off this AM, making eye contact. When nurse said good morning, he mouthed "morning" in response. Family meeting with 3 daughters 2 days ago--agree to Level 3 code status, but continue current level of care.

    Physical Examination
    General Appearance: Sedated on vent.
    Cardiovascular: Normal S1/S2
    Lungs: +Coarse BS. Decreased at Left base.
    Abdomen: Soft, Non-Tender, + Bowel Sounds
    Neuro: Sedated
    Extremities: No Calf Tenderness, + Edema with mild weeping upper extrem's, No LE edema

  4. #4
    Join Date
    Apr 2007
    Milwaukee WI

    Default Where's the time spent in critical care on note 1?

    Well, I do NOT see any indication of time spent providing critical care on note # 2 (which was the earlier date). You MUST have at least 30 minutes of direct critical care documented to use 99291.

    But the main difference seems to be that on the first note (coded 99233) the patient's cares seem to have been restricted to just treating hypotension and arrythmias. If they are cutting back on the intensity of care (even if the patient is still critically ill), then you're not providing critical care any longer.

    I'm not a physician. If the physician tells me the patient is critically ill and he provided critical care for at least 30 minutes, then I code the 99291. A patient CAN be critically ill on a ventilator for quite some time. The same patient may be still on a ventilator but sufficiently improved to no longer be deemed critical the very next day. So coding 99291 one day and 99233 the next isn't necessarily a problem.

    Also, don't forget that a critically ill patient may receive care by more than one physician; that doesn't mean each of them is providing critical care. (Classic example in our pediatric intensive care unit is the dermatologist called in to evaluate a rash on a child who is on ECMO. The child is critically ill, but this physician isn't providing critical care.)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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