Your Critical Care Reimbursement and COVID-19

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How to rise to the challenge through the pandemic.

Surviving This Surge of COVID-19 Now is the Time:


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Since the spring, emergency medicine groups have been maneuvering daily to stay financially afloat. While at the onset of the COVID-19 pandemic some epicenters of coronavirus disease were overwhelmed by an influx of patients, the majority of emergency departments across the United States were not.

Shelter in Place guidelines, canceled elective services and overall layperson fear of seeking hospital-based care led to a most unexpected decrease in ED visits nationwide. Unfortunately, the fall of 2020 has brought new challenges. In the past several weeks, COVID-19 cases have soared throughout the country.

While emergency department volumes remain overall down, acuity of patient encounters is once again trending higher. Although it’s true the majority of people infected with COVID-19 do not require medical attention, many individuals who do seek emergency department care are critically ill. If you’re feeling stressed despite seeing only 1.7 patients per hour during your shift, there’s a good reason behind that — you’re seeing sicker patients. At various points this year, Critical Care services have doubled at many hospital sites.


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These times are quite precarious for many Emergency Medicine groups — volumes are down though overall acuity is trending higher. This is the “low-volume/high-acuity paradox” of COVID-19. If your group is scrambling to remain financially solvent, there is one factor you can control. Optimize your Critical Care billing and you can be part of the solution toward your own financial recovery. This article will show you how to chart most effectively in Critical Care and optimize the reimbursement for the service you provide.

Start with a Solid Foundation Your Critical Care Time Statement:

“I spent 30 minutes of Critical Care Time with this patient. This does not include time spent on separately reported billable procedures.” When appropriate, that’s the phrase that gets you paid in emergency medicine. Always remember, regardless of the acuity of your patients or the service you provide, your Critical Care reimbursement is going nowhere without such documentation. Important times for Critical Care services reside at 30, 75 and 105 minutes (and every increment of 30 minutes beyond).

Your documentation of Critical Care time does make a difference. Based on the 2020 Medicare Physician Fee Schedule, Critical Care time (30 to 74 minutes) is reimbursed at $226.64 per encounter.[1] This amount is $49.44 above the reimbursement generated for a Level 5 (CPT 99285) encounter. Don’t leave this money on the table — it quickly adds up.


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During this era of COVID-19, if your average Critical Care service jumps to 16%, you can generate $1,878 within a single month (based on working eight-hour shifts, two patients per hour and 15 shifts a month). If your group has five other similar “main-side” shifts in a day, that’s $9,390, which stands to be realized for you and your colleagues in the month.

Next, keep in mind what your Critical Care Time service actually is — the time you spend on providing services to a critically ill or injured patient. The 2020 AMA CPT codebook defines a critical illness or injury as one that “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.”[2]

The terms “high probability” and “imminent or life-threatening deterioration” are the keys here. Unstable vital signs, while not definitively necessary to qualify for Critical Care Time services, are a good starting point to alert you to the potential of a critical care encounter.

How COVID-19 Qualifies for Critical Care:

When you think of Critical Care Time, “sick respiratory” should be one category that comes to mind. As emergency physicians are all too aware, most critically ill COVID-19 patients present in this fashion. Within this arena, “all things respiratory” should be kept in mind. The time you spend with Pulse oximeter, Chest X-ray and ABG interpretation all apply towards your Critical Care Time.

Non-invasive ventilation (i.e. BiPAP) and ventilator management time count as well. It’s important to remember that your applicable Critical Care service must occur in the context of a “high probability of imminent or life-threatening deterioration” within an encounter. Simply interpreting a Chest X-ray or ABG in an otherwise stable COVID-19 patient is not enough.

Beyond pneumonia and sepsis, patients afflicted by the SARS-coV-2 virus can possess a myriad of other illnesses as well including pulmonary embolism, myocarditis, acute kidney injury and encephalopathy.

Given their predilection for elderly age, multiple underlying medical problems, higher BMIs and/or pre-existing immunocompromised conditions, critically ill COVID-19 patients tend to be inherently medically complex. As such, a number of other interventions that count toward Critical Care Time are typically needed in their care.

Here’s what also applies:

  • Your discussion of the case with paramedics, family and / or surrogate decision makers — provided the conversation bears directly on patient management.
  • Your review of computer records.
  • Your discussions of care with the primary and/or consulting physicians.
  • Chart documentation (yes, this does count).
  • Transcutaneous pacing management.
  • Peripheral IV insertions (i.e. EJ vein), blood draws (i.e. from central lines) and OGT / NGT placements (if ER staff is unable to obtain these).

You Hold the Key to Your Financial Success:

Be mindful of the time you spend performing all of the above interventions. Strive to include this time in your next Critical Care Time statement. When appropriate, here’s how your documentation should look: “I spent 75 minutes of Critical Care Time with this patient. This does not include time spent on separately reported billable procedures.”

It’s important to note that CPR, intubation, central line, chest tube and wound repair time cannot be applied towards your billable critical care service. These are all separately reported billable procedures.  Nonetheless, stay vigilant with your documentation of these — they certainly are distinctly reimbursable.

Whatever challenge resides within your next patient encounter, charting your Critical Care Time is one of the best ways to optimize your charting and reimbursement. Pay attention to the details and you can rise to the challenge. This is one battle you can win over COVID-19.

 

References:

  1. 2020 National Physician Fee Schedule Relative Value File, GPCI20, National Physician Fee

Schedule Relative Value File Calendar Year 2020, MCR-MUE-Practitioner Services. Published by CMS. Effective: January 1, 2020.

  1. AMA Current Procedural Terminology (CPT) 2020 Professional Edition. 4th ed.

 

 

ABOUT THE AUTHOR

Dan Magdziarz, DO, is an emergency physician at Palos Hospital in Chicagoland. He is also CEO and founder of ChartOptima.com: 2018 Emergency Medicine reimbursement teaching website. You can follow on Twitter @EMreimbursement.  Share your interests and comments: dmagdziarz@chartoptima.com.

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