Critical care billing

[valianteffort]

Does anyone have a good resource for what they use to determine if critical care time was met?

I work at a shop where he have people who only bill for it in near death cases and some who do for everything they can think of.

For example, every sepsis rule out that meets sirs criteria they will put on critical care time.
Another example, alcohol withdrawal with HR of 101 requiring one dose of Valium.

I was never taught in the above manner to bill time although am I incorrectly missing this billing or are they over billing?

Thanks!

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[RustedFox]

Someone have a .pdf of that MedData critical care cheat sheet?? You know the one.

 

[CoolDoc1729]

Does anyone have a good resource for what they use to determine if critical care time was met?

I work at a shop where he have people who only bill for it in near death cases and some who do for everything they can think of.

For example, every sepsis rule out that meets sirs criteria they will put on critical care time.
Another example, alcohol withdrawal with HR of 101 requiring one dose of Valium.

I was never taught in the above manner to bill time although am I incorrectly missing this billing or are they over billing?

Thanks!

One of my colleagues bills CC for every 20 year old ab pain she gets a lactic of 2.1. I have no idea how she doesn’t get in trouble.

Your billing co can certainly provide you a list. I go by, did I actually spend more than 30 minutes doing something for this patient (rare) if I didn’t do it when I did it would they have been ok - if no then CC. I’m around 4%, my group average is around 12%, so I’m confident I don’t bill CC inappropriately ever

 

[Mount Asclepius]

One of my colleagues bills CC for every 20 year old ab pain she gets a lactic of 2.1. I have no idea how she doesn’t get in trouble.

Your billing co can certainly provide you a list. I go by, did I actually spend more than 30 minutes doing something for this patient (rare) if I didn’t do it when I did it would they have been ok - if no then CC. I’m around 4%, my group average is around 12%, so I’m confident I don’t bill CC inappropriately ever

I commend you for trying to do it right. You are likely under billing though and missing out on revenue for the work that you are rightly performing.

 

[CoolDoc1729]

I commend you for trying to do it right. You are likely under billing though and missing out on revenue for the work that you are rightly performing.

As an hourly peon.. idgaf if I’m losing my cmg money lol

 

[Mount Asclepius]

As an hourly peon.. idgaf if I’m losing my cmg money lol

Yeah, don’t make a CMG any more money. You should also change jobs. Know your worth and make money for your work. I know I preach to the choir. I can promise you though that making twice as much is potentially worth moving to somewhere you didn’t imagine you’d be. It can still involve mountains or oceans.

 

[Pudortu]

Just out of curiosity…does billing critical care automatically make a chart level 5? If so, does this continue into the new January 2023 documentation rules?

 

[CoolDoc1729]

Just out of curiosity…does billing critical care automatically make a chart level 5? If so, does this continue into the new January 2023 documentation rules?

Yes and yes, is my understanding
Source: CMG gave us 4 hours of online training re: billing changes lol

 

[Siggy]

I thought that critical care time is billed completely separate from the chart level system. It's a 99291, not a level 5 chart CPT code. I guess if you're billing less than 30 minutes, but how often does that occur outside of cardiac arrests that don't have ROSC at some point?

Also, remember that documenting goals of care discussion with the proxy counts (but not updating every last family member) and its minus separately billed procedures, which CPR time counts as. So unbilled US time counts, time documenting and talking to consultants counts. Interpreting ABGs, pulse ox, managing mechanical ventilation, vasoactive medications (cardene, norepi, epi infusions, etc) counts as CC time.

 

[LChristmas]

Here are the two resources I use to try to play within the rules of the game...

View attachment 363659

View attachment 363660

 

[CajunMedic]

This is the one I tend to go by

ED Charting and Coding: Critical Care Time

 

[Rekt]

I thought that critical care time is billed completely separate from the chart level system. It's a 99291, not a level 5 chart CPT code. I guess if you're billing less than 30 minutes, but how often does that occur outside of cardiac arrests that don't have ROSC at some point?

Also, remember that documenting goals of care discussion with the proxy counts (but not updating every last family member) and its minus separately billed procedures, which CPR time counts as. So unbilled US time counts, time documenting and talking to consultants counts. Interpreting ABGs, pulse ox, managing mechanical ventilation, vasoactive medications (cardene, norepi, epi infusions, etc) counts as CC time.

Classic example for us is STEMIs. Often in the department for 15-20 minutes. Theoretically wouldn't be that difficult hitting thirty if you include prep and phone calls, etc but not worth it. Pretty much the only time I put less than 30 minutes CCT though.

And yes CCT is automatically level 5 billing

 

[Jabbed]

Classic example for us is STEMIs. Often in the department for 15-20 minutes. Theoretically wouldn't be that difficult hitting thirty if you include prep and phone calls, etc but not worth it. Pretty much the only time I put less than 30 minutes CCT though.

And yes CCT is automatically level 5 billing

1. They don’t have to physically be in the ED for 30 minutes as the time that you spend charting, following up on labs, talking to CCU, and even following up the cath results can be included in CC time.

2. This was true at one point, but no longer under current CMS guidelines. Given the inherent complexity of MDM in CC time though, this may be the case once again in 2023 as long as your CC time is well documented.

 

[gro2001]

Does anyone have a good resource for what they use to determine if critical care time was met?

I work at a shop where he have people who only bill for it in near death cases and some who do for everything they can think of.

For example, every sepsis rule out that meets sirs criteria they will put on critical care time.
Another example, alcohol withdrawal with HR of 101 requiring one dose of Valium.

I was never taught in the above manner to bill time although am I incorrectly missing this billing or are they over billing?

Thanks!

You are probably under billing critical care time but that doesn't mean that others aren't overbilling.

The thing to keep in mind is that our jobs give us a skewed sense of what's critical. But CCT is not EM or CCM specific, it's for the whole house of medicine. So think what would an internist consider critical. So yeah, that alcohol withdrawal that was tachycardia and needed a push of IV fluids might qualify.

Another way of looking at it is: if these interventions were delayed by an hour or two, could this person die or suffer some organ damage? If yes, that's critical care. So the tachycardic withdrawal patient might count. The random low risk chest pain probably not.

Just remember to not document reflexively that they aren't in distress or something.

 

[Janders]

Some easy rules of thumb-
Are they dying? Would they have died or lost an important part without you?
Are they going to an ICU or step down?
Have you ordered any drip medication? (Heparin, nitro, pressor, dilt, etc)
Have you ordered any oxygen? (excluding, perhaps, 1-2L NC)
Have you activated any stat/code pathway (code stroke, code STEMI, code whatever)
Have you used any second/third line med bc they are sick (iv mg for asthma, IM epi for allergic reaction, etc)?
Have you given any med they are hesitant to give on the floor of your hospital? (Iv NAC, IV phenobarb, IV versed)
Have you give a big crytaloid bolus for a real reason (30mL/kg)?
Have you transferred them ALS for higher level of care?
Obviously some procedures are defacto highly associated w/ cc… intubation, chest tube, pacing, cardioverting, etc.

In my own appraisal I found a list of actions we take that are highly associated with critical care billing to be useful…

4% sounds very low to me. Even a random
Community shop should be 6-10% without stretching things much.

 

[bravotwozero]

I’m averaging 8-9% at my shop

 

[BoardingDoc]

I’m averaging 8-9% at my shop

Yarp. 8.4% for me this past year.