Critical Care and Observation times

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 • 30 minutes-74 minutes (99291): 6.3 • 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 • 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, acuterequiring 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 • 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 • Asthmaor 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 metabolicabnormalities or requiring aggressive fluid resusciation • Hyperkalemiaw/ IV treatment • Hypernatremia with mental status change requiring aggressive treatment • Severe acidosis

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