Without republishing everything that’s already been said, I admit that 
I find some of the comments a bit concerning.

The diagnosis code is not disconnected from determining the level of 
service but helps support it. In fact, more often then not, improper 
diagnosis terminology will get the physician in trouble. It is 
important the diagnosis reflect the reason for the ED visit and explain 
the work that was performed. Since “indeterminate” diagnosis such as 
‘rule out sepsis’ are not allowed in the ED setting, symptom and 
complaint based diagnosis can be very helpful.

Yes, we get paid for our ‘thinking’ but within the bounds of CMS 
documentation and CPT guidelines. However, you can’t bill for critical 
care just because its good practice to perform a timely evaluation and 
initiate treatment. An otherwise healthy 5 month-old generally does not 
need a ‘septic evaluation’ let alone antibiotics in the ED, yet there 
is a “potential” that the child could suddenly become septic. Just 
because there is this “potential” doesn’t mean the child meets the 
criteria for critical care billing.

Most payor guidelines as well as CMS require the patient to meet the 
CPT definition of critically ill or injured. The illness or injury 
“…acutely 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” (2009 CPT ©AMA). A child who is otherwise stable 
and without significant risk factors wouldn’t necessarily meet this 
standard just because they have a fever.

To say bill critical care for less then 30 minutes of dedicated patient 
care time and let the coder down-code is fraught with risk. Physicians, 
whether they actually indicate the level of service or let a coder do 
it are ultimately responsible for the billing. Marking critical care 
when the patient neither meets the time or clinical requirements is 
asking for an audit and puts you at risk for being accused of 
fraudulent billing.

While this can become an emotional issue, we need to remember that 
documentation, billing and coding standards are set by our contracts 
with the payors. If you want to change how you bill then negotiate 
these changes with them.


Jeffrey Linzer Sr., MD, FAAP, FACEP
Associate Medical Director for Compliance
Emergency Pediatric Group
Children’s Healthcare of Atlanta at Egleston and Hughes Spalding

Quoting "Martin Herman, M.D." <[log in to unmask]>:

> 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

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