I appreciate Jeff Linzer jumping in.
I believe he and I are singing from the same Psalm book on this issue.


On Tue, Jan 27, 2009 at 6:46 PM, <[log in to unmask]> wrote:

> 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 (c)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.
> jeff
> 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

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)

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