LHH Department of Neurosurgery Guideline. <pdf attached>
LHH Department of Neurosurgery Guideline. <pdf attached>
CRITICAL CARE CODES:
Document and explain why patient is critically ill. Critically ill indicates “a high probability of imminent or life-threatening deterioration in the patient’s condition.” Decision making and treatment must include an indication that the patient’s condition met that definition as well as considerations and plans to prevent life-threatening deterioration or organ system failure.
Code 99291 covers the initial 30 to 74 minutes on that day. Code 99292 covers the additional 30-minute time increments. Use 99292 when time totals 75 minutes or more. When using 99292, documentation should show why time was needed beyond the first hour.
Below is a list of the commonly encountered neurologic disorders that often justify use of critical care codes
Total time for critical care services include:
Total time for critical care services does not include:
Procedures bundled into CPT codes 99291 and 99292 that do not require separate coding include the following:
ADDITIONAL CODES FOR PROCEDURES:
Procedures that may be coded separately include:
When performing these other procedures, use modifier 25 with the critical care codes to indicate that procedures and evaluation and management were performed on the same day.
Lumbar puncture has three different CPT codes. The three CPT codes are:
Neurodiagnostic and monitoring procedures for EMG, nerve conduction studies, and EEG may be coded separately.
The following monitoring and emergency procedures also are among those commonly coded separately in the critical care unit:
ADVANCE CARE PLANNING:
Two CPT codes allow for coding of the time spent in discussions and preparation of advance care plans. These codes cannot be used by the same physician on the same day he or she uses CPT code 99291. Examples of written advance directives include healthy care proxy, durable power of attorney for health care, living will and MOLST. The two CPT codes for time spent in discussion and preparation of these forms are:
Prolonged services are not used with the primary codes 99291 and 99292. Subsequent day hospital management is coded as 99233, base time for this code is 35 minutes. When time spent exceeds base time by more than 30 minutes, physician may add a prolonged service code:
Telemedicine is coded using the standard CPT codes plus a modifier. In January 2017, the modifier of choice changed from GT to 95. Modifier 95 identifies a “synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.”
CPT specifies two codes for telehealth critical care:
When providing telehealth, use Place of Service 02, which is a new place of service code as of January 2017.
Patients covered by Medicare Part B are eligible for remote critical care only if they are hospitalized in a rural area. Medicare uses different codes for remote critical care. Medicare also makes an exception by covering certain teleconsultations for acute stroke within 4.5 hours of symptom onset. The critical care telehealth codes for patients with Medicare are included in the Healthcare Common Procedure Coding System:
INTERPROFESSIONAL TELEPHONE CONSULTATIONS:
A neurointensivist might provide a telephone consultation directly with a physician who is caring for a patient at a remote hospital. These circumstances include urgent situations where a timely face-to-face service with the consultant may not be feasible. The codes may not be used if the consultant has or will see the patient within 14 days. This code is not to arrange for transfer of care. The time for the service may include review of records and images if the time consulting with the primary physician is more than half of the documented time. The code may be used only once per week for the same patient by the same physician.
The CPT codes for interprofessional telephone/Internet consultations are as follows:
All CPT codes listed above are copyrighted. CPT © 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Nuwer, M. and Vespa, P. (2018). Neurocritical Care Coding for Neurologists. CONTINUUM: Lifelong Learning in Neurology, 24(6), pp.1800-1809.
This score is used for patients with intracerebral hemorrhages with intraventricular extension, and is not appropriate for pure intraventricular hemorrhages.
In this score, each lateral ventricle is graded as:
3rd and 4th ventricles receive a score of:
Hydrocephalus was coded as
The formula for calculating the IVH score is as follows:
Or simplified: 3(RV+LV) + III + IV + 3(H)
Once the IVH score has been computed, the IVH volume can be calculated using the following formula:
To make things simpler, here is a table showing the calculated IVH volume based on the IVH score.
Here are two examples of IVH scores calculated for you:
How to use the IVH Score?
With the IVH score, cutoff of 40 mL indicates poor outcome and 60 mL, mortality.
With the ICH score, cutoff is 25 mL and 30 mL respectively.
The total volume of hemorrhage can be calculated by adding the ICH volume (using the ABC/2 formula) and the IVH volume (using the ICH score). Total volume predicts outcome better than ICH volume alone.
NOTE: Be wary of using ICH score and IVH score to withdraw care. Early limitation of care in ICH / IVH is a self-fulfilling prophecy which is, of course, associated with mortality.
Hallevi, H., Dar, N., Barreto, A., Morales, M., Martin-Schild, S., Abraham, A., Walker, K., Gonzales, N., Illoh, K., Grotta, J. and Savitz, S. (2009). The IVH Score: A novel tool for estimating intraventricular hemorrhage volume: Clinical and research implications*. Critical Care Medicine, 37(3), pp.969-e1.
Errolozdalga.com. (2018). [online] Available at: http://errolozdalga.com/medicine/pages/OtherPages/shcAntibiogram2010.pdf [Accessed 6 Nov. 2018].
Interesting analysis from Annals of Internal Medicine. The decision to start anticoagulation in atrial fibrillation, using CHADSVASC score is not so clear cut. See tables below.
Shah, S., Eckman, M., Aspberg, S., Go, A. and Singer, D. (2018). Effect of Variation in Published Stroke Rates on the Net Clinical Benefit of Anticoagulation for Atrial Fibrillation. Annals of Internal Medicine.
WHEN IS STRESS DOSE STEROIDS INDICATED?
STEROIDS BASED ON TYPE AND DURATION OF SURGERY
MINOR PROCEDURES / LOCAL ANESTHESIA – stress dose not necessary, take AM steroids
MODERATE SURGICAL STRESS: (eg. LE revascularization, total joint replacement)
MAJOR SURGICAL STRESS (e.g open heart surgery, proctocolectomy, esophagogastrectomy)
Uptodate.com. (2018). UpToDate. [online] Available at: http://www.uptodate.com/contents/the-management-of-the-surgical-patient-taking-glucocorticoids?search=stress+dose+steroids&source=search_result&selectedTitle=1~60#H6 [Accessed 25 Mar. 2018].