charting-and-coding from ALIEM
Huge potential for disagreement when assigning CPT-4 codes (Annals EM 40:3, 2002)
CC, ROS, PFSH may be separate or all in HPI. May be recorded by ancillary staff, but physician must write that they are reviewed and agreed with.
Must document on all charts
Need 4 Descriptive elements from following:
- Quality (e.g. sharp, blood tinged, same as prior, fullness, etc.)
- Modifying Factors
- Severity (e.g. number scale, high, increasing, moderate, fell six feet, etc.)
- Timing (e.g. two times, sporadic, waxing/waning, for three hours, etc.)
- Context (how, why, where, what)
Also include associated signs and symptoms
Mention Mode of Arrival
Altered Mental Status
Can use caveat for history, but must document why and any other attempts to get history from other sources
Document all sources of information
And what you found or note you found nothing new
Past, Family, Social Hist (PFSH)
PFSH not required for Levels 1,2, 3
Must have one item from any of the three for level 4
Must have two of three for level 5 and Crit Care
Review of Systems (ROS)
ROS with positive responses should be documented, otherwise can right all other systems reviewed and negative
- Constitutional-well developed well nourished WDWN
- Psych-oriented x 3 with good recall for recent/remote
- Eyes-pupils conjunctiva or sclera
- ENT and Mouth-tm intact or good dentition
- Resp-CTA B
- CV-heart or jvd or arterial exam
- GI-must include palpation, percussion and/or auscaltation. Must include either deep palpation noting masses or auscaltation
- GU-can either be external exam of urethra and bladder or internal pelvic. For male either meatus and bladder or scrotum/penis/testes
- Neuro: must have CN and DTRS or sens or motor
- Musculoskeletal-must document rom in addition to tenderness/swelling
Level 2 or 3 requires 2 to 4 body areas or systems
4 requires 5-7 body systems or organs
Level 5 and Crit Care requires 8 organ systems (not body areas)
Con: VS noted, WDWN,
Neck: Supple, No JVD
ENT: TMs Clear
Eyes: PERL, EOMI
Resp: Lungs CTA
CV: Heart S1S2
GI: Abdomen NT, NABS
Each notation can count towards only one system
Medical Decision Making
Record all tests or at minimum the abnormals
Interpret the studies
List treatment options and response to treatments
Quality of diagnosis is more important than number of diagnoses
Discussions with admitting team, consultants, specialists
Need two of three factors:
Four or more possible diagnoses or management options
Must also document whether problem is improving, worsening, or same
Document oxygen admin and films to contribute to MDM
Four or more elements of data or tests to review
May simply initial a report containing the results
Must interpret not just review the labs/xrays
High risk of complications, morbidity, or mortality
1 point each
- ordering clinical lab tests, radiology, or medicine tests
- discussing tests with performing physician
- decision to obtain history from additional source
2 points each
- the actual review of the other sources of information (old record, ems, nursing home records, family)
- Indepedant visualization of x-rays, ekgs, or specimens
Teaching Physician Note
I performed a hist and phys exam of the patient and discussed his management with the resident. I reviewed the resident note and agree with the documented findings and plan of care
Use descriptive rather than definitive diagnoses
EKG interp must include 3 of 6
St Seg Change
Comparison to Prior
Summary of clinical condition
Can also interp the monitor strip which should include rate and rhythm
Pulse ox: % o2, value, and assessment, ie. Good oxygenation
Unstable or patients requiring treatment or they will become unstable
Patients should be admitted, transferred, or expire
<30 min=E&M level >30 min=CCT
Time Spent: Documenting
Talking with patient and Family
Talking with EMS
Performing Bundled procedures
Review of tests/films, talking with consultants, eval and treatment, charting all count
Must write number of CCT minutes
Services Bundled in Crit Care Time
CO Output Interpretation
Interpretation of data stored in computer
Time spent reviewing test results on the patient, discussing care with other medical staff about the patient, documenting the medical record for the patient and talking to the family (if the patient cannot give an adequate history due to incompetence or inability to communicate) are all considered part of critical care time. Time spent discussing emergency treatment options with family is also considered as time in critical care including DNR status (regular updates and emotional support do not count). Time supervising or teaching is not included and delegated care of any kind is not included. 1) Interpretation of cardiac output measurements 2) Reading chest x-rays 3) Blood gases 4) Blood drawn for specimen (new this year) 5) Data retrieval 6) NGT 7) Pulse oximetry 8) Transcutaneous pacemaker 9) Ventilator management 10) Vascular access procedure 11) Family medical psychotherapy
Pts who leave before being seen
Pt called, not in waiting room
Attempted to contact
Pt walked out without notice to ED staff
No one in waiting room knew patient
Triage nurse states pt appeared stable, without distress when evaluated
Pt seemed competent to understand
No relatives or friends were with pt
Called social services to attempt to contact
Moderate (Conscious) Sedation The moderate (conscious) sedation codes have undergone a dramatic revision that affects emergency medicine significantly, particularly in the scenario where the emergency physician is providing moderate sedation in support of another specialist, such as an orthopedist or plastic surgeon. The commonly used moderate sedation (formerly called conscious sedation) codes 99141 and 99142 have been deleted. In their place, there is a new set of codes for moderate sedation that fall into two groups: The same practitioner providing both the sedation and performing the procedure, or Two practitioners are involved with one practitioner supervising the sedation in support of a second physician performing the procedure. These two sets of codes are then further delineated based on the age of the patient and the amount of time the service is provided. Scenario 1 – Single provider Codes 99143 (for patients younger than 5 years old) and 99144 (for patients 5 years or older) are used to report moderate sedation services when the same physician is both overseeing the sedation and performing the procedure. Both 99143 and 99144 are reported for the first 30 minutes of intra-service time. Intra-service time refers to the time actually spent providing the service as opposed to pre-time, preparing to start, or post-time, after the procedure is complete. CPT defines moderate sedation time as starting with the administration of the sedating drug, requiring continuous face-to-face attendance, and ending at the conclusion of personal contact by the physician providing the sedation. Recovery time cannot be counted as intra-service time. Code 99145 is available to report additional 15 minute increments of time. Scenario 2- In support of another provider To report moderate sedation provided in support of a second physician who is performing the procedure, 99148 is reported for children younger than 5 years old, and 99149 is reported for patients 5 years and older. 99150 is available to report additional 15 minute increments of moderate sedation that go beyond the 30 minutes ascribed to 99148 and 99149. Keep in mind that in 2005, there was a new directive that bundled the work of conscious sedation into many procedures. CPT created Appendix G that lists more than 250 codes bundling conscious sedation including several that are relevant to emergency medicine, such as the codes for chest tube insertion, pericardiocentesis, insertion transvenous pacemaker, insertion pediatric central line, insertion pediatric pic line, transcutaneous pacing, and elective cardioversion. In the scenario where the same physician is providing both moderate sedation services and performing the procedure, it would not be appropriate to report moderate sedation using codes 99143 and 99144 if the procedure is listed in Appendix G. However, it is recognized that there may be some circumstances in the emergency department where the emergency physician is performing moderate sedation while another physician performs a procedure on the patient. In this case, the moderate sedation codes 99148 and 99149 may be reported even if the procedure is listed in Appendix G. ACEP represents the specialty of emergency medicine and was actively involved in guiding these codes through the CPT and Relative Value Scale Update Committee (RUC) processes. The Centers for Medicare and Medicaid Services (CMS) released its 2006 fee schedule November 2005 and assigned no relative value unit (RVU) value to the emergency department after-hours code or moderate sedation, meaning CMS will not pay for either service. CMS did not assign any RVU value to the previous after-hours and moderate sedation codes, either. However, CMS officials did state in the Nov. 21, 2005 Federal Register, We are uncertain whether the RUC assigned values are appropriate and have carrier priced these codes in order to gather information for utilization and proper pricing, so a RVU from CMS could occur in the future, which is good news for emergency medicine. Other payers will make their own payment policies regarding special services codes and moderate sedation.
Conscious Sedation Codes
Conscious sedation codes ( CPT 99141 , 99142 ) have been deleted and their description changed to “moderate sedation services”. These codes are billed based on time and the age of the patient; less than 5 years (99143) or 5 years and above (99144). The time intervals are 1 unit for the first 30 minutes and then 1 unit for each additional 15 minutes (99145). The time interval is based on your continuous face-to-face attendance. Additional codes have been added to use when we are only providing the sedation services and a specialist is performing the surgical services (99148-99150). There is no Medicare allowed amount indicated for this yet but other payers have historically paid for conscious sedation.
The ideal documentation for the moderate sedation services would be in a paragraph separate from the surgical procedure being performed. State ” My face-to-face attendance began at .. and ended at ..” and then indicate the drugs used and how the patient tolerated the sedation procedure. (Note the difference between attendance and “attention” that you think of for critical care).
IV Infusion Codes
IV infusion codes (90760-90779) have become both time and drug sensitive. The ideal documentation by the provider would clearly indicate these 4 things: time of the infusion, your direct supervision during this time, medications used (or if just for hydration, indicate this), and patient’s response to the infusion.
Burn codes (16020-16030) are driven by the % of the total body surface area burned and/or more than one extremity, whole extremity, whole face, etc. The ideal documentation would indicate what you did for the dressing or debridement, the body area (s) burned, degree of the burn and % burned.
If your group bills for 12 lead EKGs be sure you include at least 3 elements in your interpretation. Remember that the rate and/or rhythm count as only one element. If you get in the habit of commenting on what is important to the patient in the axis, segments or intervals, whether an old EKG was available for comparison and your final interpretation (normal, no acute disease, acute MI, etc), you will be able to bill for this very important service each time you provide it.
If your group bills for x-rays always be sure to include the number of views you’re interpreting and be sure that each area x-rayed gets its own paragraph and appropriate interpretation. If you document x-rays of the C spine, chest and pelvis as ” all negative,” you’ve just lost the equivalent of a 99282 patient. A single view chest x-ray has a RVU value of .25 and a 2 view chest x-ray interpretation has an RVU value of .30, a 20% increase. How many of these will you interpret this month?
Critical Care Codes
Many emergency physicians still struggle with what type of patient presentations constitute critical care. The average ED patient is very ill compared to the average patient in the big house of medicine. I tell my physicians to picture the scenario as if the patient were presenting to an office-based practitioner’s office. What would the management feel like to that physician?
The fact that you knew what to do, that it was easy for you to take care of the patient and that the patient got better doesn’t mean you weren’t providing critical care services.
You should develop the habit of asking yourself about critical care time on all patients that go to a unit bed, or would be going to a unit bed if you hadn’t intervened emergently, and all patients with significantly abnormal vital signs (pending organ failure) or significant mental status changes. Remember your time intervals (30-74 minutes) and to subtract time for any separately billable procedures performed and time spent supervising residents.
Author: Andrea Brault, MD, FAAEM, MMM
Dr. Brault is President of Emergency Groups’ Office, Arcadia, CA and is Co-Chair of the AAEM Reimbursement Committee
REIMBURSEMENT ESSENTIALS FOR CRITICAL CARE
Critical care is the service that defines emergency medicine to many patients and most payers. There is great value in having this life-saving service immediately available to any patient at any time, without regard for the ability to pay. Emergency medicine ought to ” own” this code but its definition has changed seven times since 1991, so it is not surprising that this is one of the more under-reported services in emergency medicine.
Key Elements Defining Critical Care
The most recent changes have given the clearest and most beneficial definition to emergency care. Three key elements of critical care are now defined as follows:
- ” there is a high probability of sudden, clinically significant, or life threatening deterioration ” Critical care no longer requires unstable vital signs.
- ” which requires the highest level of physician preparedness to intervene urgently.” There is no physician more prepared to intervene urgently in any patient’s care than the emergency physician. This defines the specialty.
- Involving “direct personal management”, the absence of which “would likely result in sudden, clinically significant or life threatening deterioration ” If you did nothing for the patient, what is the potential that they could have a sudden unwelcome result? If that probability is high, critical care is in order.
Thus, vital signs can remain stable and the patient still have the immediate potential for life threatening organ failure, even when that failure has been prevented by your intervention. It is not uncommon that patients presenting critically ill receive care that prevents deterioration such that the patient can later be safely discharged. Patients with respiratory complaints associated with asthma, CHF, croup or severe allergic reactions all receive critical care at times and may occasionally be discharged after a stay in the ED.
Saving the patient’s life, then saving the need for an admission, is an exceptionally valuable service.
Examples abound of critically ill patients. If withholding aggressive nebulizer treatments, racemic epi or other drugs of aggressive management would likely result in “a high probability of imminent or life threatening deterioration”, critical care is being performed by their administration. Those with various arrhythmias, unstable angina, or active chest pain not easily relieved by sublinqual nitro who must be treated aggressively with IV medications and observed over time are candidates for reporting critical care.
Asthmatics with a recent history of admission for asthma, who are not responding quickly to treatment and require aggressive IV medication management, commonly meet this definition of critical care. The November 2, 1999 Federal Register even noted that “many patients with an acute exacerbation of congestive heart failure, regardless of severity, could meet the new definition of critical illness.” CFR 64 No 211, p.59423.
The old critical care term “constant attendance ” has been replaced with the term “constant attention”. Attendance implied a physical place, like the bedside; “attention” indicates the true value of critical care, it is a cognitive service rendered when the physician is thinking about how to resolve the patient’s potential for crisis.
Historically, proceduralists have defined the payment system; surgeons pioneered the health insurance industry in the 1920s (the Baylor University Plan for it’s faculty later extended to the community and lead to the founding of Blue Cross). Payment was for ” doing” something to the patient. With Medicare’s Physician Payment Reform in 1991, the emphasis now is on paying physicians for thinking, or for doing the right (quality-oriented) things. Complex thinking about possible life-threatening outcomes is principally in the domain of the ED visit level, but thinking about how to prevent the patient from crashing right now is the domain of critical care.
Critical Care RVU Value
By Medicare’s calculation, 30-74 minutes of critical care pays 37% more than a 99285 with fewer documentation requirements. However, in the relative scheme of things, critical care is still much under-valued. Consider that the work value of a simple cataract removal that can take 7-10 minutes to do, has a Medicare work value of 8.19, more than twice the 4.0 work value assigned to critical care.
No amount of HPI, ROS, medical, family or social history, or exam content is specified to support the claim for critical care; only that the chart supports the time the physician claimed was spent performing critical care and that the patient had the immediate potential for clinically significant deterioration.
This can be a subjective condition; the physician should describe concerns about the patient’s potential imminent decline.
CPT Time Analysis
CPT clarifies more of what is included in critical care time:
Time spent with the individual patient should be recorded in the patient’s record. The time that can be reported as critical care is the time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit. For example, time spent on the unit or at the nursing station on the floor reviewing test results or imaging studies, discussing the critically ill patient’s care with other medical staff or documenting critical care services in the medical record would be reported as critical care, even though it does not occur at the bedside. Also, when the patient is unable or clinically incompetent to participate in discussions, time spent on the floor or unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care, provided that the conversation bears directly on the management of the patient.
Time spent in activities that occur outside of the unit of off the floor (eg. telephone calls, whether taken at home, in the office, or elsewhere in the hospital) may not be reported as critical care since the physician is not immediately available to the patient. Time spent in activities that do not directly contribute to the treatment of the patient may not be reported as critical care, even if they are performed in the critical care unit (eg, participation in administrative meetings or telephone calls to discuss other patients). Time spent performing separately reportable procedures or services should not be included in the time reported as critical care time.
Code 99291 is used to report the first 30-74 minutes of critical care on a given date. It should be used only once per date even if the time spent by the physician is not continuous on that date. Critical care of less than 30 minutes total duration on a given date should be reported with the appropriate E/M code.
Code 99292 is used to report each additional 30 minutes beyond the first 74 minutes. It also may be used to report the final 15-30 minutes of critical care on a given date. Critical care of less than 15 minutes beyond the first 74 minutes or less than 15 minutes beyond the final 30 minutes is not reported separately.
Time flies when you are absorbed in your work and it is common that emergency physicians forget what commonly goes in to their care of the patient with the immediate potential for medical crisis. The following figure identifies several of these time-consuming critical care services.
CPT Time Analysis Chart and Examples
Medicare and CPT have provided exact instructions for how to count and report time. The first 30 74 minutes of critical care is to be reported using code 99291. Less than 30 minutes is to be reported with the appropriate E/M code. Each 30 minutes beyond 74 minutes is reported with an additional one-half hour code 99292.
Time spent when the physician is not immediately available to the patient does not count towards critical care, for example, phone calls from home/office, or radio command in the ED. Time spent performing other procedures that will be billed in addition to critical care and time spent by residents who are performing critical care are also not reportable.
Time is also defined specifically by date, not by 24-hour periods. In 1994, time in the CPT methodology was changed from “day” to “date” so that the critical care clock starts over at midnight .
Critical care started at 11:35pm with the episode continuing until 12:30am.
Report: Use an E/M service on first date of service because less than 30 minutes was performed on that date and report 99291 (First hour) on the second date of service.
Critical care started at 11:30pm with episode continuing until 12:30am.
Report: Report 99291 (First hour) on first date of service and 99291 (First hour) on the second date of service. Two different dates represent two different services.
Include in the chart a statement of the aggregate time of attention spent on the patient throughout their ED stay but discount the time spent performing separately reportable procedures. This time statement is an estimate. There is no precise proxy that can stand in place of your time of attention because critical care is mental work done when you are immediately available to the patient. Make a mental note of the time spent on procedures and deduct that time from your total attention to the patient.
Check the CPT manual to see exactly which procedures are bundled into critical care. They include only the following codes: 93561, 93562, 71010, 71015, 71020, 94760, 94761, 94762, 99090, 43752, 91105, 92953, 94656, 94657, 94660, 94662, 36000, 36410, 36415, 36600. These are all minor procedures, like reading a chest film, placing an NG tube, starting an IV, and ventilation management. Anything not listed above is separately billable, including EKGs and rhythm strip interpretations, which many payers wrongly try to bundle into to critical care payment.
Definition of “Critical”
The chart must meet two tests:
First, the condition of the patient must clearly involve a “high probability of sudden, clinically significant, or life threatening deterioration which requires the highest level of physician preparedness to intervene urgently” or unambiguously indicate an unstable medical condition or potential for life-threatening condition.
Second, the physician must actually intervene by providing “frequent personal assessment and manipulation”. The physician’s intervention must be documented. You should document performance of “direct personal management” as a form of intervention.
Documentation of Critical Care
Specifically, state your personal management of the patient during his/her critical period, by describing what the period involved. Write a sentence describing that the “high probability of _________ required my full and direct attention, intervention and personal management for ___ minutes while the patient was critical.”
The entire chart is necessary to support critical care time, as nursing assessment notes, procedure notes, medication rates and routes of administration, etc. substantiate the patient’s critical status. To fully support the claim for critical care the chart should note the time of both physician and nursing events (initial physician exam, re-exams, IV order times, dosage and medication changes.) The picture is clearer when both nursing and physician notes are available for review.
A good critical care procedure note would include comments about the patient’s progress throughout their ED stay, specific responses to each intervention as well as comments about multiple vital sign or exam assessments. Drug therapy start times, routes and rates of administration, along with the results of diagnostic tests and procedures should be clear in the chart. These are a means of supporting the patient’s clinical condition and help to reflect the time spent in the patient’s care.
Medicare’s documentation standard is the physician’s own note regarding total time spent in patient care. It is best to conclude critical care documentation with a ” procedure note” describing your activities and decision making while the patient was under your care. Note here how long pain lasted or vital signs were unstable, what was tried to alleviate it and at what time the patient no longer needed critical care attention.
By CPT’s definition, critical care is now clearly not an exclusive E/M service and can be billed in addition to an E/M service in some cases, because:
- It has no history, exam or MD M component
- Only E/M services of the same type must be combined on the same day.
- CPT clearly does not bundle 9928x codes in with critical care. Critical care and other E/M services may be provided to the same patient on the same date by the same physician Any services performed which are not listed above should be reported separately. (01 CPT, p. 18) [An] emergency department code may be reported in addition to the critical care service code(s) if both services are provided by the same physician on the same day.
Medicare is more restrictive. Only when a patient receives an evaluation and management service first, then later in the same visit becomes critical, can you report both an E/M service and critical care on the same date of service.
Physicians should always note in the chart when critical care started after the initial evaluation.
Author: Mr. James R. Blakeman
List of Spurs for Crit Care Billing
Billing observation care is appropriate when the service provided exceeds that of the care provided for typical 99284 or 99285 cases. These are the patients with complex presentations or complex dispositions for which admission is a real possibility, but not a foregone conclusion. The use of time as a clinical tool is your key to understanding which patients these codes apply to.
CPT gives examples of admitted patients that are candidates for observation. I’ve included the following clinical scenarios as examples of possible observation care to which I’ve added some clarifying comments: chest pain (especially if you are running repeat enzymes and/or stress test), asthma (with a prolonged course of treatment), abdominal pain (for reassessments), renal calculi (if prolonged pain management), dehydration (if prolonged hydration and oral challenge documented), drug ingestions/overdose (classic six hour observation but not if obvious admission), or alcohol intoxication (likely these are ALOC for which time will tell you it was just the ETOH) or severe allergic reactions (for reassessments).
Time is not a clinical tool when (examples):
- You are waiting for test results that take a long time to come back.
- You are waiting for an inpatient bed.
- You are waiting for another provider to see the patient.
- You are waiting for tests to be run in the morning when the service is available.
- You are waiting for transportation for the discharged patient.
There are codes for when the patient’s entire course occurs on one calendar day and other codes for when the course crosses over two calendar days. Medicare has a minimum requirement of an eight-hour stay for the one day course but no time requirement when observation continues past midnight. CPT has no minimum time frame, so ask your billing company what they use. The key for the provider to remember is that they must document the time when observation is started.
Observation is a “status,” not a physical bed location. The physician invokes this when the order for observation is made. The hospital does not need to change the registration status of the emergency patient in order for physician observation to be paid. If you realize that reimbursement for observation services can be 40-80% higher than for emergency E&M levels, depending on the codes used, and that physician observation care does not require an observation services unit, you will find significant additional revenue in properly reporting observation care.
The minimum standard for what must be documented for observation adds these four elements to what would normally be written for an emergency patient. Most physicians find it easier to simply add an “Observation Note” at the end of their normal dictation style rather than trying to change styles of documenting.
- Notation of the time of initial exam with a supporting order note, like “observation was performed beginning at time………. to determine the need for admission and to observe for changes in the patient’s status of………” You can get the clock started as early as the time of initial exam by noting that time also. (Your statement should be from a proactive position, not the usual, “the patient was observed ”).
- Re-exams are not mandatory, but document them when they are done. (Highly recommended, if the patient didn’t need to be re-examined, why did you keep him in the ED?)
- Discharge note summarizing your conclusions: “obs revealed xxx.” Time of discharge can support the end time for obs.
- History requires a past medical, social AND family, not like the high level ED history that requires only two of these three elements. (Get in the habit of simply documenting this on all of your sick patients. If you forget and then try to make it an observation patient, the cost of downcoding is severe).
CPT HPI PE MDM 2008 RVU* Not adjusted for Budget Neutrality 99284 Detailed Detailed Moderate 3.17 99285 Comprehensive Comprehensive High 4.72 99217 combined with 99219 or 99220 for diff/day DC 1.85 99219 Comprehensive Comprehensive Moderate 2.89 99220 Comprehensive Comprehensive High 4.06 99235 Comprehensive Comprehensive Moderate 4.63 99236 Comprehensive Comprehensive High 5.77 99291 High 5.90
Author: Andrea Brault, MD FAAEM MMM President, Emergency Groups’ Office