Lost in TranslatYIN – October 2024

Gooooood Moooorning NES!

I hope you all are doing well. I wanted to thank all of you who have recently reached out to me and expressed their thoughts on my newsletter. Shout out to all of our providers at St. Michael’s and all of our providers in Amarillo, Texas. I’ll be honest, the idea for the newsletter was a bit spontaneous and ironically wasn’t even my idea. Never once in my residency did, I think that I would be writing a monthly documentation newsletter. The paths that we choose don’t always take us where we want to go. Sometimes they take us where we need to go.

This month’s newsletter will focus again on critical care. Some of our sites have really done a tremendous job in increasing their critical care billing. Thank you all for your efforts. However, I know we can still do better. In general, if your Emergency Department has about a 20% patient admission rate, then your critical care billing should be between 10-12% of all patients. If your admission rate is 25% then it should be about 15%. One might say, Dr. Yin, that means almost half of patients that we see should be billed as critical care. I would say to that provider “yes indeed they should be.” Last time we spoke about critical care documentation we touched on different diagnoses that would result in critical care. Some of the diagnoses were anaphylaxis, severe hyperkalemia, acute psychosis, afib with RVR. We also talked about how critical care does not depend on disposition. This month we are going to focus on critical care from a different perspective.

As an ED provider, I like to associate certain diagnoses with critical care. This is how my brain works. However, there is another way to look at critical care. There are numerous high-risk medications that are also associated with critical care. I’m sure all of us have seen patients who came to the ED because they went to CVS or their primary care physician and their blood pressure was 200s. I get 2 or 3 of these patients in my ED per day. These patients get a work up and end up getting IV hydralazine or IV labetalol. Usually these patient’s work ups are normal and we discharge them to follow up with their pcp. The diagnosis is either be asymptomatic HTN or hypertensive urgency. Did you know that IV hydralazine and IV labetalol are considered high risk medications? Meaning that these patients are considered critical care. You might think to yourself, “I give IV labetalol 3-4 times a day!” Then I would say to you, that’s 3-4 more critical care patients for you.

Based on our last critical care discussion, we all know that afib with RVR is considered critical care. Usually, these patients receive IV cardizem or IV lopressor. Both IV cardizem and IV lopressor are considered high risk (critical care) medications. Giving these medications are what makes afib with RVR a critical care diagnosis. Here in Ohio, we often have patients who come in that overdose on fentanyl. The fentanyl around here is very long acting and requires multiple doses of IV narcan. Multiple doses of IV narcan is considered critical care. Multiple doses of ativan, multiple doses of d50, multiple doses of IV lasix, and multiple doses of sublingual nitroglycerin are all also considered critical care medications.

Did you all know that the only FDA approved indication for TXA is heavy vaginal bleeding? I give IV TXA all the time here in my EDs. Usually for traumas, head bleeds, or GI bleeds but not usually heavy vaginal bleeding. However, did you also know that TXA is also a high risk (critical care medicine) medication? I attached a word document with all the high-risk medications that we give. When these high risk medications are given, these patients are considered critical care.

After you read the complete list of high risk (critical care) medications you will soon realize that you give about half of all your admitted patients receive these high risk (critical care) medications. Hence, this is why when the admission rate of your ED is about 20% then your critical care should be roughly 10-12%. The bottom line is, you all are so efficient and amazing at your jobs that what we consider simple and mundane, is actually critical care in the eyes of CMS. I just want you all to get credit for the work that you all are doing.

As always, thank you all for listening and for your hard work and appreciation. It does not go unnoticed.

Humbly yours,

David Yin

Critical Care Medications