Critical Care Coding

Challenges:

- Unexplained Low Collections
- Lack of Understanding of the documentation rules and their application of various critical care codes.
- Physician groups can have wide internal variances in critical care documentation because of complex usage criteria and lack of training

PhyCon's Continuous Daily
Documentation Education

PhyCon sends every physician client an email report when we find a chart has been downcoded.
The email notes the patient's record number and why it was down-coded.
The physician soon learns to put the correct information in the next record so it can be properly documented for correct coding. This includes critical care time, medical medical
decision documentation, and a host of other deficiencies the coder discovers.

“PhyCon stays on top of the billing and works each account to discover if something isn't paid and they figure out why, They contact the potential payer and to work on resolving the issue. As part of the value-ad to their service they place more effort & more time to collect all that's possible."
-- Emergency Physician Group Medical Director

Great Confusion Remains

As we travel throughout this country providing documentation lectures to our physicians and clients, the most frequently asked questions are those concerning Critical Care documentation. Immediately when the physicians hear those words they crumble into a dearth of confounding confusion, and justifiable rage.

'We've heard this lecture before and we still don't get it!' They know it is important because its lots of money lost. They have to listen to this menagerie of ifs, ands, & buts courtesy of the CMS abundant rules, exceptions and diverging scenarios committee.

Just minutes later after this learning session, it flies out of this perpetual anatomy class once again, only to be confused again the next time they see a critical care patient throwing up blood in their face and screaming in pain. Trust me, they would rather relearn the anatomical intricacies concerning the entanglement of the brachial plexus that controls the little finger or find the lost Ark of the Covenant than hear this lecture again.

So, with great consternation, we are about to divulge into one case study, yes I said one example, to explain every rule, regulation, outlier, and standard deviation that exists in creation of the black hole of critical care. But prior to that we are going to explain WHY we even want to learn this example; Fore not the reasons that are about to be proclaimed you probably would not care.

Tell the Patient's Story

We all have had great teachers in our professional career, and we recall many of the facts to this day. Mine was an internal medicine oncology professor who obviously knew a lot about medicine. After reading my hand-written history and physical examination, he said one thing I'll always remember:

"You know Dr. Orcutt, you have all the parts to the history and patient exam, but you have not told the Story. I asked "What do you mean?". "You need to tell a story in the chronological order of who, what, when, and where did the patient become sick or injured, and share what you did in detail how you attempted to intervene in the process no matter the outcome of the patient." This really stuck with me.

Solving the Issue with Strict Oversight
Understand the Financial Impact

For an emergency group serving 52,000 patients per year, this figure translates to over $1,000,000 annually. Most private insurers will reimburse greater which will impact this amount more.

Your unwillingness to address critical care documentation will impact your group and your hospital and eventually this could cause you to be in an uncomfortable situation. Many physicians also do not completely understand what qualifies for a critical care, such as a child arrives with very severe asthma and a low pulse ox and after aggressive treatment is later sent home. They ask how is it critical care if you discharge the patient but the physician did not completely understand the CMS definition of critical care.

In Internal Medicine/Emergency Medicine/Critical Care Medicine Residency, Critical Care has been defined as the delivery of medical care to "any patient who is physiologically unstable, requiring constant and minute-to-minute titration of therapy according to the evolution of the disease process."

Of course this child met the criteria of a critical care patient, not by the definition CMS gives, but this is the definition most clearly produced by the aforementioned specialties. It's all about the timing of the disease process and its course. It need not be an imminent demise of the patient to qualify for critical care, but the threat of this demise caused you to perform a prompt intervention (i.e. continuous Albuterol upgrafts) or you directly performed a procedure such as RSI to prevent this patient's lungs from failing. Even if you promptly intervene and simply slowed the process of an organ system(s) deteriorating, you have met the definition of critical care. As defined by AMA CPT 2018, a critical illness is an “illness or injury [which]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.”

The CMS definition uses more stark verbiage, such as “imminent,” “high probability,” and “life-threatening deterioration.” Of course you should use these in your patient documentation, but this sounds like a patient that has already slipped and halfway down the grave.

This is confusing to many physicians because some don't remember that applying emergent care to a declining organ system disease is a critical care intervention, but they are preventing the acute, near-death experience in the patient.

This is one of the two most critical areas of the the report to dictate and get very specific. Most of you have voice dictation. Get precise. I will discuss much more in the next article about what you should say and report. The second is in your medical decision making documentation This has become the hottest topic in emergency medicine reimbursement, which will be discussed in a separate article.

Paul Orcutt MD FACEP
CEO
PhyCon Inc