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

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

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

14. 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

15. 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.

16. 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