Again, I have to disagree. The child has to have something that mandates the
intervention and not just the possibility of a bad thing. SO while I agree
that the CPT code and the diagnosis ar enot necessarily linked, there is a
threshold that must be passed. The idea of time critical antibiotics is not
really applicable in the infants with fever. Now if there is shock, even
comensated, especially if suspected septic shock, we are in agreement.
However just the workup alone isn't critical care.
MArty
On Mon, Jan 26, 2009 at 10:56 PM, Amy & Allen Fink <[log in to unmask]> wrote:
> Again I insist that the ultimate diagnosis is uncoupled form the em code it
> is the evaluation process and critical thinking skills that are rewarded
> with the cc code. ie we treat many with chest pain, nl ekg but concerning
> stories who get iv nitro, bblockers and heparin admitted and ultimately end
> up with no acs and a non cardiac diagnosis. these are critical care cases.
> It is the process, not the diagnosis that is important. what is/are the
> critical diagnosis to evaluate for, if that diagnosis exists is there a
> potential for decompensation.
> This is how emergency medicine differs from most other specialties. We are
> concerned for a 5% potential for the devastating diagnosis and embark on
> highly invasive time sensitive evaluations to rule out these potentials. so
> when I see a 5 mo old with 103 temp, I say this could be meningitis or
> sepsis, until I can prove its not....and that is critical care time, after I
> prove its not then critical care time ends.
>
> This is not unethical. This is getting paid for what you think and do. If
> the child ends up with a aseptic meningitis picture which is not really a
> hard diagnosis until after neg cultures, as early bacterial meningitis could
> have a similar differential, then that's great for the kid, but my process
> for evaluation was the same as if they had bacterial meningitis.
>
> I agree that all kids who have a lp for fever are not CC, but a child who
> gets a rapid evaluation, labs, cultures, LP and tiem depemdant ABX clearly
> is.
>
> al
>
> 
> *From:* "Martin Herman, M.D." <[log in to unmask]>
> *To:* Amy & Allen Fink <[log in to unmask]>
> *Sent:* Monday, January 26, 2009 7:26:50 PM
> *Subject:* Re: CC coding
>
> what if you find aseptic meningitis? The child would not be very
> symptomatic? IS that CC. or is it a comprehensive visit with the nature of
> the presenting problem being life threatening?
>
> I reall ythink to be ethical about it, there is a difference between
> critical care and a comprehensive E&M. That is the child who needed the CC
> had an imminent life or organ threatening condition that warranted your
> stepping in to treat or prevent some deterioration. THe 99285 is not
> imminent but naturally has a risk associated with its conditions.
>
> Marty
>
>
>
>
> On Mon, Jan 26, 2009 at 9:06 PM, Amy & Allen Fink <[log in to unmask]>wrote:
>
>> If you evaluate a child less than 6 weeks and find bacterial meningitis
>> and admit that child to the icu is this not critical care. Critical care is
>> not coupled to the diagnosis, so if you do the same evaluation, for the same
>> reason and find no concern for SBI how is this not critical care?
>>
>> 
>> *From:* "Martin Herman, M.D." <[log in to unmask]>
>> *To:* Amy & Allen Fink <[log in to unmask]>
>> *Sent:* Monday, January 26, 2009 6:39:08 PM
>> *Subject:* Re: CC coding
>>
>> I think the majority of coders would argue that just doing a sepsis workup
>> is not critical care.
>>
>> Clearly it qualifies for either a detailed or comprehensive visit. I just
>> can't make the argument that having a kid get a SWU is critical care.
>>
>> How is you can argue that there is a high liklihood that doing nothing
>> would result in the kid decompensating? I can't.
>> Can you even argue that the kid has a chance of being admitted to the ICU?
>> . NO!>
>> In fact if the kid is > 4 weeks, he may even be discharged. Besides I can
>> make an argument for not doing an LP in those kids that are > 6 weeks of
>> age.
>>
>> I am willing to be educated. Make the argument..
>>
>> Marty
>>
>>
>>
>> On Mon, Jan 26, 2009 at 8:10 PM, Amy & Allen Fink <[log in to unmask]>wrote:
>>
>>> Of course this is critical care. Clearly you are evaluating for a
>>> potentially critical diagnosis, and therefor is critical care. The length of
>>> time involved in the evaluation is really immaterial and you should document
>>> critical care time even if it is less than 30 min, although you cannot
>>> bill for less than 30 min. This encounter should then be downcoded to a
>>> comprehensive, independent of individual comprehensive requirements. The
>>> final diagnosis has little bearing on cc in fact you can discharge critical
>>> care patients from the ed (the anaphylactic reaction that requires epi, then
>>> is dc'd later is clearly critical care.)
>>>
>>>
>>> a
>>> 
>>> *From:* "Martin Herman, M.D." <[log in to unmask]>
>>> *To:* [log in to unmask]
>>> *Sent:* Monday, January 26, 2009 12:32:46 PM
>>> *Subject:* Re: CC coding
>>>
>>> I have not . Of course if the infant is really septic, then yes. I think
>>> the
>>> CC requirements that the physician's energy is needed to support, or
>>> prevent
>>> a failing organ system is a good one to use as a gauge.
>>> There are lots of things that come to the ED that I spend more than 31
>>> minutes on when you consider H&P, treatment, consultation and management
>>> and
>>> documentation. How about the crying infant? How about the suspected child
>>> sexual abuse? I am sure we can find lots of other examples.
>>>
>>> I am sorry that there is time and expertise involved in working up a
>>> febrile
>>> infant but that alone doesn't constitute critical care.
>>> How many times is that febrile infant actually septic? 1% maybe if you
>>> stretch it. Most of the time we spend way too much money , time and
>>> effort
>>> on an otherwise normal child with a cold.
>>>
>>> I can't see anyway to justify CC unless the baby is having apnea, or is
>>> in
>>> shock (compensated or not).
>>>
>>> Marty
>>>
>>>
>>> On Mon, Jan 26, 2009 at 1:40 PM, <[log in to unmask]> wrote:
>>>
>>> > Does anyone out there in Ped EM land code for critical care for your
>>> "rule
>>> > out sepsis" patients.
>>> >
>>> >
>>> > ?
>>> >
>>> >
>>> > If we have direct pt. care of 30 minutes, not including a spinal tap,
>>> are
>>> > talking to PMD's, reviewing office and / or birth records, reviewing
>>> and
>>> > documenting labs, updating parents, documenting repeat exams, going
>>> through
>>> > admit process....
>>> >
>>> >
>>> > ?
>>> >
>>> >
>>> > Just curious what our thoughts are, and any other
>>> tips/tricks/suggestions
>>> > on CC coding.
>>> >
>>> >
>>> > Thanks,
>>> >
>>> >
>>> >
>>> >
>>> >
>>> >
>>> >
>>> > Dr. Todd Zimmerman
>>> >
>>> >
>>> >
>>> >
>>> >
>>> >
>>> >
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>>> & gt;
>>> >
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>>> >
>>> >
>>> >
>>> >
>>> > ** CONFIDENTIALITY NOTICE: This email and its attachments may contain
>>> > confidential, proprietary, and/or privileged information which is
>>> legally
>>> > protected from disclosure. Any review, retransmission, dissemination,
>>> or
>>> > other use of this information by persons or entities other than the
>>> intended
>>> > recipient is strictly prohibited. If you received this email in error,
>>> > please notify the sender immediately and appropriately delete the
>>> material
>>> > from your computer. Thank you.
>>> >
>>> >
>>> > For more information, send mail to [log in to unmask] with
>>> the
>>> > message: info PEDEML
>>> > The URL for the PEDEML Web Page is:
>>> > http://listserv.brown.edu/pedeml.html
>>> >
>>>
>>>
>>>
>>> 
>>> Marty
>>> Martin Herman, M.D.
>>> Pediatric Emergency Specialists, P.C.
>>> Lebonheur Children's Medical Center
>>> Memphis Tn 38103
>>> 901 405 1407 ( office)
>>> 901 219 9202 ( cell)
>>> 901 287 5986 ( ED office)
>>> 901 287 6226 ( ED fax)
>>>
>>> For more information, send mail to [log in to unmask] with the
>>> message: info PEDEML
>>> The URL for the PEDEML Web Page is:
>>> http://listserv.brown.edu/pedeml.html
>>> *
>>>
>>>
>>
>>
>> 
>> Marty
>> Martin Herman, M.D.
>> Pediatric Emergency Specialists, P.C.
>> Lebonheur Children's Medical Center
>> Memphis Tn 38103
>> 901 405 1407 ( office)
>> 901 219 9202 ( cell)
>> 901 287 5986 ( ED office)
>> 901 287 6226 ( ED fax)
>>
>>
>>
>>
>>
>
>
> 
> Marty
> Martin Herman, M.D.
> Pediatric Emergency Specialists, P.C.
> Lebonheur Children's Medical Center
> Memphis Tn 38103
> 901 405 1407 ( office)
> 901 219 9202 ( cell)
> 901 287 5986 ( ED office)
> 901 287 6226 ( ED fax)
>
>
>
>
>

Marty
Martin Herman, M.D.
Pediatric Emergency Specialists, P.C.
Lebonheur Children's Medical Center
Memphis Tn 38103
901 405 1407 ( office)
901 219 9202 ( cell)
901 287 5986 ( ED office)
901 287 6226 ( ED fax)
For more information, send mail to [log in to unmask] with the message: info PEDEML
The URL for the PEDEML Web Page is:
http://listserv.brown.edu/pedeml.html
