A critical time to be back

It's been several months since the last post.  I hope you haven't forgotten the pearls I've previously posted. This is a good time to review my previous posts for a quick refresher.

Now is a great time to talk about critical care billing.  There has been a substantial change in what our coders will allow to be documented.

SUMMARY  OF  DOCUMENTING PEARLS

• Patient must meet definition of critical care
• Time spent delivering critical care must exceed 30 minutes
• Time spent performing procedure may not count towards critical care time
• Only time spent by Attending and Resident or Attending alone may count towards critical care time.
• Document TIMED re-evaluations
• CHS will allow the following statements of time: 1. Specific time amount (i.e. 33 minutes) or 2. "in excess of 30 minutes."  THEY WILL NOT ALLOW A RANGE ("30-74 minutes").  HINT: DO NOT USE THE PROVIDED CLICK BOX 
• Critical care attestations should be patient specific!  Critical care billing is highly compensated, thus highly audited.  Templated statements that are not patient specific may get rejected by insurance companies.

3 ELEMENTS OF CRITICAL CARE

• CRITICAL ILLNESS:  “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;”
• CRITICAL INTERVENTION: involving “high complexity decision making to assess, manipulate, and support vital organ system failure;”
• TIME: The duration of critical care services  is based on the physician’s documentation of total time spent evaluating, managing, and providing care to the critical patient, as well as time spent in documenting such activities.  For example, time spent can be at the bedside, reviewing test results, discussing the case with staff, documenting the medical record and time spent with family members (or surrogate decision makers) discussing specific treatment issues when the patient is unable or clinically incompetent to participate in providing history or making management decisions.​

KEY DOCUMENTATION REQUIREMENTS

• Illness or Injury and Treatment provided meet the definition of critical care (defined by CPT and Medicare).  CPT defines critical care as "decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient's condition."  Medicare adds "the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient's condition."
• Total Critical Care time delivered must be at least 30 minutes
• ​Documentation must include physician's interval assessments of the patient's condition, any "impairments of organ systems" based on all relevant data available to the physician (i.e. symptoms, signs and diagnostic data), the rationale and timing of interventions and the patient's response to treatment.
• It is recommended that the physician note "the time involved in the performance of separately reportable procedures was not counted toward critical care time."

MEDICARE REQUIREMENTS FOR TEACHING ATTESTATIONS

• Time spent alone by the resident cannot be counted towards critical care
• Only time spent by resident and attending or attending alone can count towards critical care
• Attending may refer to resident documentation for specific history and physical exam finding as well as MDM
•  Attending must document:
  

1. ​ The total time the teaching physician personally spent providing critical care 
   
2. The patient was critically ill when the teaching physician saw the patient
   
3. What made the patient critically ill
   
4. The nature of the treatment and management provided by the teaching physician.

• Example provided by CMS: "Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident’s documentation and I agree with the resident’s assessment and plan of care."

Finally, I've included the following table outlining RVU compensation as a reminder of why documenting is so important.  Critical care billing increased RVU generation by approximately 25% over a Level 5 chart.