Critical Care and Observation times Larry Halem, MD, CPC VEP Regional Productivity Director

E+M Levels There are 5 E+M levels (evaluation and management codes) Level 1 (99281): 0.6 RVU Level 2 (99282): 1.17 RVU Level 3 (99283): 1.75 RVU Level 4 (99284): 3.32 RVU Level 5 (99285): 4.9 RVU

Critical Care Critical Care for 30 minutes-74 minutes For each additional 30 minutes (99292): 3.17

Critical Care Defined as the high probability of sudden or life threatening deterioration It involves direct personal management but not direct bedside care Average for group and providers should be 6-9% based on Medicare reviews Percentage will also vary per institution: typically it is 40% of your admit rate

Critical Care Must be equal or greater than 30 minutes Anything above 74 minutes codes at higher level of critical care Must document that this excludes time spent during procedures

Critical Care Exam of the critical patient Critical patients are in distress Respiratory patients are not only generally distressed but they are in respiratory distress The coder needs to understand what the patient looks like in your exam

Critical Care The MDM is what makes the difference in critical care documentation Explain to the coder why the patient is critical Explain what life saving interventions were performed Use terms the coder can pick up on Severe or moderate distress, imminent deterioration, risk of end organ injury, risk of respiratory failure

Critical Care Diagnosis Matters The diagnosis you put and the order you put them in matters for critical care Your first diagnosis is what codes Make it the most acute diagnosis

Common Critical Care Diagnosis Acute Coronary Syndrome, Angina, Myocardial infarction with aggressive management Bleeding or severe anemia requiring a transfusion GI bleeding requiring drips such as protonix or octreotide Anaphylaxis or angioedema Atrial fibrillation or SVT or rapid heart rate not responding immediately to treatment Asthma or COPD requiring multiple continuous nebulizer treatments CHF with pulmonary edema or severe exacerbation requiring treatment Pulmonary edema or emboli requiring emergent anticoagulation Dehydration w/ significant metabolic abnormalities or requiring aggressive fluid resusciation Hyperkalemia w/ IV treatment Hypernatremia with mental status change requiring aggressive treatment Severe acidosis Sepsis/severe sepsis/septic shock requiring immediate IV antibiotics and aggressive fluid management Intracranial hemorrhage requiring treatment or frequent monitoring Trauma requiring extensive treatment and management life or limb threatening Pneumothorax requiring emergent treatment or with respiratory distress requiring monitoring Stroke, acute requiring activation of code stroke and possible administration of TPA Psychiatric patient, requiring chemical/physical restraints Overdose requiring intense monitoring or aggressive treatment Unstable vital signs requiring intervention Seizure, requiring IV therapies in ER to stop and treat the seizure or status epilepticus

Observation time Observation time is used to care for patients observed in the ER for an extended period of time in order to determine their need for admission Examples: Abdominal pain requiring multiple studies or re-exams, chest pain requiring serial troponin

Observation time It must be for a minimum of 3 hours 2.5 hours with frequent reassessments It must be minimum of 8 hours for Medicare Medicaid does not pay for observation

Observation time Observation Note: Patient has no family history that is relevant to this complaint. Patient first seen at (time) on (date) Observation began at (time) on (date) and was necessary in order to determine *** Upon re-evaluation, observation revealed that the patient should be (admitted/discharged). Patient discharged at (time) on (date). Total time of observation: *** hours

Observation time Level 4 patient billed observation time (99219): 4.78 Level 5 patient billed observation time (99220): 6.16

Observation time: crossing midnight When a patient crosses a midnight for observation, they need observation note and a discharge note Example: Patient seen at 9pm and placed on observation and then discharged at 2am

Observation time: crossing midnight Discharge note: During patients observation in the ER, (tests/labs/interventions) performed. Exam: General: NAD, alert and awake Cardiovascular: RRR without murmur Lungs: CTA bilateral Abdomen: soft, non tender, non- distended Patient will follow up with their primary care physician in 2-3 days . Patient instructed to return for worsening symptoms.

Observation time: crossing midnight Level 4 patient billed observation time (99219): 3.84 Level 5 patient billed observation time (99220): 5.25 Discharge note adds: 2.06 ***This bills higher than critical care