Critical Care

I believe both notes qualify for CC. I'm just not sure how to bill it.

doc 1 states:
4/16/2015 11:00 AM
Patient seen, examined and discussed with PA. The patient had been admitted the night before from Owosso and developed worsening respiratory failure. He was transferred on what sounds like a high flow system. Placed on NRB here initially and then BiPAP. When I evaluated the patient he was on high flow oxygen. His saturations with 40 L flow and 100% oxygen were only 86%. I had a very lengthy discussion with his wife at the bedside about his respiratory failure and that he will more than likely require intubation. She states that if there is some ay to get the patient better that she would like for him to be intubated. He does have abnormalities on his CXR, really needs repeat CT scan. Apparently history of pulmonary fibrosis. There was mention of lung mass, will defer to new CT scan. I discussed the case with the hospitalist, Dr. Obrien and the ICU resident. Will transfer to the ICU.

The patient has a high probability of sudden, clinically significant deterioration, which requires the highest level of physician preparedness to intervene urgently. I managed/supervised life or organ supporting interventions that required frequent physician assessment. I devoted my full attention to the direct care of this patient for the period of time indicated below. Time spent with family or surrogate(s) is indicated only if the patient was incapable of providing the necessary information or participating in medical decision making. Time devoted to teaching and any procedures I billed separately is not included. Total critical care time was 60 minutes.

Acute on chronic respiratory failure
Pt appeared to be in distress and declining will transfer to ICU, may need to be intubated.

doc 2 states:
Patient seen and examined with the resident on rounds. I agree with the history, physical, assessment and plan with the below noted modifications. Patient seen earlier by pulmonary service at the LTAC for worsening hypoxemia. Recently transferred over from Owosso. Had been hospitalized there for about a week and treated with supplemental oxygen and antibiotic therapy. Apparently had imaging over there including a CT scan which was unavailable for review. Earlier today was noted to be more hypoxemic and obtunded. Stat arterial blood gas demonstrated worsening respiratory acidosis/hypercapnia. On physical examination he will arouse easily of present is conversant and follows commands. Currently on BiPAP 10/5 cm of water. Chest x-ray reviewed from earlier this morning. Demonstrates significant alveolar opacities throughout the left lung more so in the left lower lobe. The right lung field is relatively clear although has low lung volumes.

Assessment:
Acute on chronic hypercapnic hypoxic respiratory failure requiring noninvasive positive pressure ventilation
Acute encephalopathy
Consolidation throughout left lung, pneumonia versus mass
COPD/pulmonary fibrosis by history
Inflammatory bowel disease/Crohn's disease, on biologic therapy

Plan:

PAP increased to 15 cm of water and EPAP increased to 8-10 cm of water
Repeat ABG in 2 hours
Continue IV antibiotics
CT of the chest when clinically stable
Aspiration precautions
Urinary antigens for strep, Legionella histoplasmosis
Fungal precipitins

The patient has a high probability of sudden, clinically significant deterioration, which requires the highest level of physician preparedness to intervene urgently. I managed/supervised life or organ supporting interventions that required frequent physician assessment. I devoted my full attention to the direct care of this patient for the period of time indicated below. Time spent with family or surrogate(s) is indicated only if the patient was incapable of providing the necessary information or participating in medical decision making. Time devoted to teaching and any procedures I billed separately is not included.
Total critical care time was 40 minutes 1545-1625

Critical Care