Lost in TranslatYIN – June 2024

Dear NES Providers,
     I hope you all are doing well. Summer is almost upon us! I hope you all are doing well and hope that you are able to enjoy this summer to the fullest.  
     June’s Documentation topic is all about Critical Care. Critical Care Documentation will be a topic of conversation for each and every single Emergency Department you work in for the rest of your career. I can promise you this. Thus, it’s best to master this topic now because it will never go away.  
 Early in my career, I used to only bill critical care for STEMIs, patients that I intubated, and patients that I central lined. I was wrong. What most ED physicians think of as critical care is very different from what CMS considers critical care. Critical care is defined as a critical illness or injury that impairs one or more vital organ systems such as there is a high probability of imminent or life-threatening deterioration in the patient’s condition. Pretty broad definition, right? I agree. The theme of Critical Care is that you are a strong and capable clinician and sometimes the patients that we resuscitate and the procedures that we perform come so naturally that we don’t think twice about it. However, to most, what you are doing is amazing. Never forget that.  
     As I mentioned previously, I used to only bill Critical Care when I intubated a patient, central lined a patient, called the nephrologist for emergent dialysis, etc. However, there are so many other instances that are considered critical care. Instead of learning about the high-risk medications used in critical care and learning the high-risk scenarios for critical care, I’m going to give you a bunch of diagnoses that are frequently billed as Critical Care. Naturally, anybody admitted to the ICU would be considered critical care. You would be correct. However, there are patients that are considered critical care even if they are discharged home. For example, a patient who is allergic to peanuts, goes out and has a cookie that they did not know what cooked in peanut oil. That patient comes in with shortness of breath and hives. You astutely give that patient IM epinephrine, IV Benadryl, IV Pepcid, IV Solumedrol. You reassess them and they are good as new and discharge the patient. That patient counts as Critical Care. If you have a patient that has a history of atrial fibrillation that already takes Eliquis comes in with palpitations. Patient’s HR is in the 140s. You give that patient a couple doses of IV Lopressor, cardiac enzymes and BNP are normal and you send that patient home. Also, Critical Care Time. If you have a patient that comes in psychotic and you give them IM Haldol, IM Ativan, IM Benadryl and you observe that patient for what feels like 1278 hours and eventually discharge them. This patient too qualifies for Critical Care Time. If you a patient comes in for HTN and their blood pressure is 220s/110s and you give them a couple doses of IV Labetalol or IV Hydralazine and eventually start them on Norvasc and send them home, this as you guessed it is Critical 
Care Time. I think you all get the point. Critical Care does not depend on disposition. If a patient is admitted to the ICU or taken immediately for intervention to the Cardiac Cath lab or surgery, absolutely please bill critical care time. However, there are also scenarios where Critical Care Time is appropriate even if the patient is discharged home.  
      Here are some other diagnoses that qualify as Critical care Time. NSTEMI with active chest pain, renal failure, liver failure, SVT (that gets a dose of adenosine), DKA, Acute Appendicitis, Atrial fibrillation/Atrial flutter with RVR (new onset or existing), Hyponatremia < 120, Hyperkalemia > 6.5, Acute Psychosis, Pulmonary edema, Hemorrhagic stroke, Septic Shock, Testicular torsion, Acute Arterial Occlusion, Anemia (requiring blood transfusion). In general, if you use the word “failure” in your diagnosis, you should be documenting Critical Care Time. If you give a patient blood (even if the patient’s baseline Hb is 7), this is Critical Care Time. For reference, I attached a word document that I created that you all can print off and use as a guide for diagnoses that qualify for Critical Care Time. I printed this document off and taped it above the physician’s computers at my sites. Feel free to do the same. Just FYI, just because the diagnosis is not on the list does not mean it can’t be critical care time. I wanted to limit myself to one page, there are more diagnoses out there that would also qualify. 
      When documenting Critical Care time, the code 99291 is used for any patient that you take care of for 30 to 74 minutes. This CPT code accounts for 6.31 RVU. For comparison, a level 5 chart (99285) accounts for 5.21 RVU.  Do not bill for less than 30 minutes of Critical Care time. Some might think that I only spent 5 minutes at the bedside with this STEMI that I sent to the cath lab. How can I bill 30 minutes? The time used for critical care time is not just the time you spent at the bedside. This total time includes review of prior records, ordering labs, reviewing labs, reviewing imaging, documenting, and time spent with the patient and family. When all those times are added in totality, it easily totals 30 minutes for that STEMI patient. The code 99292 is used for every 30 minutes additional Critical Care Time after 74 minutes. This code accounts for an additional 3.17 RVU. Therefore, you can see how important documentation is for those two-hour long marathon codes that we get from time to time.  Lastly, all I want to do is state that we are not trying to up-code these critical patients. I am just trying to get your credit for the hard work that you are already doing. Remember, the theme of Critical Care time is that you all are very strong and capable. Critical Care Documentation is recognition of your extraordinary efforts by CMS. Thank you all for reading. 
As always, if you have any questions, please feel free to contact me.  
Humbly yours,
David Yin