Billing Levels (Based on 1995 Medicare Guidelines)

	Level 1	Level 2	Level 3	Level 4	Level 5	Critical Care (instead of Level 5, 4-5% of patients)
HPI	1-3 elements	1-3 elements	1-3 elements	4 elements	4 elements	-
ROS	0 system	1 system	1 system	2-9 systems	10 systems	-
PMH/FHx/SocHx	0 element	0 element	0 element	1 element	2 elements	-
Physical Exam	1 system	2 body systems	2-4 body systems	5-7 body systems	8 body systems	-
RVU's (~$36.04 per RVU in 2019)	0.59	1.16	1.73	3.3	4.85	6.27

Chief Complaint

• Chest pain, rash, blurry vision, etc.
  

HPI Elements

• Location (left sided chest pain)
• Quality (sharp, achy, dull)
• Severity (mild, moderate, 10/10)
• Duration (started 2-3 days ago)
• Timing (constant, intermittent lasting 30 minutes but comes back)
• Context (occurs at rest, occurs with exertion)
• Modifying factors (better with rest, worse with spicy foods)
• Associated symptoms (nausea, headache, SOB)

ROS ("Nausea and vomiting" are 2 symptoms but only count for one system)

• Allergic/Immunologic
• Cardiovascular
• Constitutional Symptoms
• Ears, Nose, Mouth, Throat
• Endocrine
• Eye
• Gastrointestinal
• Genitourinary
• Hematologic/Lymph
• Integumentary
• Musculoskeletal
• Neurological
  
• Psychiatric
  
• Respiratory
  

PMH/FHx/SocHx

• PMH (HTN, DM, HL)
• FHx (HTN)
• SocHx (smokes crack, lives in a house)

Physical Exam ("RRR and no murmurs" are two exam findings but only one system)

• Constitutional
• Eyes
• ENT
• Respiratory
• Cardiovascular
• GI
• GU
• Skin
• MSK
• Psychiatric
• Neuro
• Lymphatic/Hematologic

Medical Decision Making (demonstrates why this patient is a Level 5)

• Differential Diagnosis
• Document potential diagnosis and/or risks
  
• DVT - could progress to PE and cause death
• Why is this a medical emergency?
• "The patient has had back pain for months but pain worsened in intensity and duration last night so came to ER"
• Interventions
• IVF because this patient's BP is low
• Re-Assess
• "Pt re-assessed, still with labored breathing and wheezing, will benefit from additional nebulizer treatments and continued cardiac and respiratory monitoring in the ED"
• "CP still present s/p SL Nitro, still concerned for ACS, will tx pain with opioids"

Critical Care Time (Minimum time is 30 minutes, next is 75-104, 105-134)

• Conditions to consider CCT
  
• Sepsis
• DKA or DM with MS changes
• Acid/Base disorders
• Delirium
• HTN Emergency
• AMI
• 2nd and 3rd Degree AV Block
• VT/VF
• SAH/SDH
• Respiratory Distress
• Acute Renal Failure - high K+
• Fracture of vertebrae
• Poly-trauma +/- shock
• Time (must be over 30 minutes)
  
• Time at bedside
• Time reviewing labs/imaging
• Time spent speaking with consultants or family
• Time spent documenting
• Document
• "I performed Critical Care on this patient"
• "This patient needed Critical Care because their hyperklaemia could cause cardiac deterioration without immediate the aggressive and active interventions I performed"
• Aggressive interventions
• IV drips (Insulin, Dopamine, Cardizem, Nitro, Dilantin, Heparin, etc)
• Thrombolytics
• Large volume IVF boluses
• Repeat nebulizer Tx's (1 hour of continuous)
• Intubation/BiPAP
• Blood products
• Cardioversion
• Narcotics for trauma patients in pain
• Anti-arrythmics (atropine, adenosine)
• Procedures
• NG tube
• Transcutaneous pacing
• Ventilator management
• Peripheral access
• Separately Billable Procedures (time spent doing these does NOT count towards critical care time)
  
• CPR
• Intubation and/or verification of ET placement with DL
• tPA administration
• EMS direction
• Central Lines
• Wound repairs

Wound Care

• Billed per length of wound and complexity
• Length
1. < 2.5 cm
2. 2.51 - 5 cm
3. 5.01 - 7.5 cm
• Complex repairs
• Requires debridement or multiple foreign body removal
• Requires closure in layers

EKG (must have 3 of 6 elements)

1. Rhythm and rate
2. Axis
3. Intervals
4. ST segment changes
5. Comparison to prior EKG
6. Summary interpretation