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Archive for June, 2006


Starting July 1 AMAC will check on call schedules, age of
patient and code 11 as listed in complaint column.

If it is weekdays between 8A and 6 PM they will call the
social worker for adult or peds code 11s and connect to the
charge nurse in the area.

Off these hours and on weekends they will page the SAVI
advocate on call and connect to the charge nurse in the
area. SAVI can also be activated thru AMAC for domestic
violence cases off hours. Advocates provide information to
survivors and are present to provide emotional support,
encourage follow up. They do not perform exams or evidence

We have some shifts covered for the forensic portion of the
sexual assualt exam and evidence collection. For patients
listed as code 11 in the triage complaint, AMAC will call
the SAFE if there is one on the schedule and connect to the
Attending in the area. They will also notify the Attending
if there is NOT a SAFE so that the Attending can designate
the appropriate HCW to perform the exam. We are working to
expand this program.

Thank you for your support.
Barbara Richardson, MD, SAFE
Deb Travis, RN, SANE-A

ADDENDUM: from Dwayne Raymond, RN

Both photographs and NON-IBEX documentation of the physical
exam, Comprehensive Sexual Assault Form (CSAF) usually
found in the SAVI packets – SHOULD BE SECURED IN THE LOCK

The logbook can be found in the lockbox of the SAVI cabinet.
PLEASE, do not leave anything in the metal cabinet of the
medication room.

Written by phil

June 30th, 2006 at 6:13 pm

Posted in Pearls

Prevention of Unrecognized Arterial Cannulation

The possibility of arterial cannulation during attempted central venous access is well recognized. Classic findings of arterial cannulation such as pulsatile bright red blood are notoriously unrelieable markers of catheter location. When unwanted arterial cannulation is suspected, the catheter should be removed and a new attempt at venous cannulation made. To reduce the possiblity of unrecognized arterial cannulation, the following guidelines must be adhered to:

1. Use ultrasound guidance where possible to minimize the risk of arterial puncture.

2. Confirm placement of internal jugular or subclavian central line placement with chest radiograph. Three key features should be assessed.
a. First, the catheter should lie in the vena cava, outside of the cardiac silhouette.
b. Second, the catheter should be relatively parallel to the walls of the vena cava.
c. Third, the catheter tip should not abut the wall of the vena cava.

3. If obtaining a cxr is not feasible for any reason or there is any doubt regarding location after cxr, the critical care committee recommends confirmation by:
a. Manometry (transduce waveform)
b. Comparative Blood Gas Analysis – draw samples from the catheter and an artery
c. Contrast Dye Study


1. Scott WL. Complications associated with central venous catheters. A survey. Chest. 1988; 94:1221-1224.
2. Brandt RL, Foley WJ, Fink GH, et al. Mechanism of perforation of the heart with production of hydropericardium by a venous catheter and its prevention. Am J Surg. 1970; 119:311-316.
3. Sheep RE, Guiney WB. Fatal cardiac tamponade: Occurrence with other complications after left internal jugular vein catheterization. JAMA. 1982; 248:1632-1635.
4. Bar-Joseph G, Galvis AG. Perforation of the heart by central venous catheters in infants: Guidelines to diagnosis and management. J Ped Surg. 1983; 18:284-287.
5. Collier PE, Ryan JJ, Diamond DL. Cardiac tamponade from central venous catheters — A report of a case and review of the English literature. Angiology. 1984; 35:595-600.
6. Maschke SP, Rogove HJ. Cardiac tamponade associated with a multilumen central venous catheter. Crit Care Med. 1984; 12:611-613.
7. Tocino IM, Watanabe A. Impending catheter perforation of superior vena cava: Radiographic recognition. Am J Roentgenol. 1986; 146:487-490.
8. Jiha JG, Weinberg GL, Laurito CE. Intraoperative cardiac tamponade after central venous cannulation. Anesth Analg. 1996; 82:664-665.
9. Bunegin L, Albin MS, Helsel PE, et al. Positioning the right atrial catheter: A model for reappraisal. Anesthesiology. 1981; 55:343-348.
10. Jobes DR, Schwartz AJ, Greenhow DE, et al. Safer jugular vein cannulation: Recognition of arterial puncture and preferential use of the external jugular route. Anesthesiology. 1983; 59:353-355.

Written by phil

June 25th, 2006 at 4:55 pm

Posted in Pearls

Resuscitation Room Supplies

with 2 comments

The MSH Emergency Department Resuscitation Room has the following supplies available by cabinet:



HD Monitoring Setup

Storage cabinet bottom shelf

EtCO2 supplies

Airway cart bottom drawer

Central Line Dressings


Written by phil

June 21st, 2006 at 1:15 pm

Posted in Pearls

Phone Numbers

atomic wings 4103800
BC Deli 212-996-0649
Caribeano Resturant 831-3906
Dump. King 212-410-2700
El Paso restaurant 996-1509
Famiglia . 212-996-9797
Ferny Deli 12123694922
FIRST WOK 410-7747
Isohama . 212-828-0099
Jackson Hole 1212-427-2825
Manhat. Indian . 212-932-7720
one fish two fish 369-5677
Peters . 45014
ray’s pizza 12123483855
roosters resturant 8312492
Saigon Grill . 212-996-4600
SPICY resturant 996-2310
Three Guys . 212-348-3800
yoan ming garden chinese food 97 & mad 212 426 9545

Written by phil

June 15th, 2006 at 12:09 am

Posted in Food

MSH Women’s Health Services Referral Guidelines

Indications for Referral
Threatened abortion
Dysfunctional uterine bleeding (H/H>30)
Post-partum patients
Urinary tract infection
Pelvic inflammatory disease
Sexually transmitted diseases
Contraception (all forms)
Routine Gyn exam
Pelvic pain

Refer to Specialty Clinics
Colposcopy (Abnormal PAP) -> Pt with abnormal PAP smear
Cystometrics (Urinary Incontinence) Speciality clinics

Refer to JMF Clinic not GYN
Sexual assault patients

Refer to Gyn Surgery Clinic
Possible ectopic pregnancy (ASAP or send to ER)
Missed ab confirmed (ASAP)
Bartholin cyst/abscess (1 week//use Word Catheter)
Ovarian cyst premenopausal pt (>5 cm) (1-2 wk)
Ovarian cyst postmenopausal pt (any size) (1-2 wk)
Pt requiring elective surgery (1-2 wk)
Fibroids(symptomatic or >12 wk) [3-4 wk; If H/H <30, w/in 1 wk]
DUB unresponsive to treatment [3-4 wk; If H/H <30, w/in 1 wk]
Cysto/rectocele 3-4 wk (needs neg urine C&S)
Uterine prolapse 3-4 wk
Other Gyn pathology 3-4 wk

Refer to Infertility Clinic
Gyn endocrine disorder

Written by phil

June 12th, 2006 at 7:39 pm

Posted in Pearls

Critical Care Documentation and Billing

This info graciously borrowed from AAEM Dollars and Sense. Thanks Shkelzen.

Critical Care Codes

Many emergency physicians still struggle with what type of patient presentations constitute critical care. The average ED patient is very ill compared to the average patient in the big house of medicine. I tell my physicians to picture the scenario as if the patient were presenting to an office-based practitioner’s office. What would the management feel like to that physician?

The fact that you knew what to do, that it was easy for you to take care of the patient and that the patient got better doesn’t mean you weren’t providing critical care services.

You should develop the habit of asking yourself about critical care time on all patients that go to a unit bed, or would be going to a unit bed if you hadn’t intervened emergently, and all patients with significantly abnormal vital signs (pending organ failure) or significant mental status changes. Remember your time intervals (30-74 minutes) and to subtract time for any separately billable procedures performed and time spent supervising residents.

Author: Andrea Brault, MD, FAAEM, MMM

Dr. Brault is President of Emergency Groups’ Office, Arcadia, CA and is Co-Chair of the AAEM Reimbursement Committee

Critical care is the service that defines emergency medicine to many patients and most payers. There is great value in having this life-saving service immediately available to any patient at any time, without regard for the ability to pay. Emergency medicine ought to ” own” this code but its definition has changed seven times since 1991, so it is not surprising that this is one of the more under-reported services in emergency medicine.

Key Elements Defining Critical Care

The most recent changes have given the clearest and most beneficial definition to emergency care. Three key elements of critical care are now defined as follows:

” … there is a high probability of sudden, clinically significant, or life threatening deterioration…” Critical care no longer requires unstable vital signs.

” … which requires the highest level of physician preparedness to intervene urgently.” There is no physician more prepared to intervene urgently in any patient’s care than the emergency physician. This defines the specialty.

Involving “direct personal management”, the absence of which “would likely result in sudden, clinically significant or life threatening deterioration…” If you did nothing for the patient, what is the potential that they could have a sudden unwelcome result? If that probability is high, critical care is in order.

Thus, vital signs can remain stable and the patient still have the immediate potential for life threatening organ failure, even when that failure has been prevented by your intervention. It is not uncommon that patients presenting critically ill receive care that prevents deterioration such that the patient can later be safely discharged. Patients with respiratory complaints associated with asthma, CHF, croup or severe allergic reactions all receive critical care at times and may occasionally be discharged after a stay in the ED.

Saving the patient’s life, then saving the need for an admission, is an exceptionally valuable service.

Examples abound of critically ill patients. If withholding aggressive nebulizer treatments, racemic epi or other drugs of aggressive management would likely result in “a high probability of imminent or life threatening deterioration”, critical care is being performed by their administration. Those with various arrhythmias, unstable angina, or active chest pain not easily relieved by sublinqual nitro who must be treated aggressively with IV medications and observed over time are candidates for reporting critical care.

Asthmatics with a recent history of admission for asthma, who are not responding quickly to treatment and require aggressive IV medication management, commonly meet this definition of critical care. The November 2, 1999 Federal Register even noted that “many patients with an acute exacerbation of congestive heart failure, regardless of severity, could meet the new definition of critical illness.” CFR 64 No 211, p.59423.

“Constant Attention”

The old critical care term “constant attendance ” has been replaced with the term “constant attention”. Attendance implied a physical place, like the bedside; “attention” indicates the true value of critical care, it is a cognitive service rendered when the physician is thinking about how to resolve the patient’s potential for crisis.

Historically, proceduralists have defined the payment system; surgeons pioneered the health insurance industry in the 1920s (the Baylor University Plan for it’s faculty later extended to the community and lead to the founding of Blue Cross). Payment was for ” doing” something to the patient. With Medicare’s Physician Payment Reform in 1991, the emphasis now is on paying physicians for thinking, or for doing the right (quality-oriented) things. Complex thinking about possible life-threatening outcomes is principally in the domain of the ED visit level, but thinking about how to prevent the patient from crashing right now is the domain of critical care.

Critical Care RVU Value

By Medicare’s calculation, 30-74 minutes of critical care pays 37% more than a 99285 with fewer documentation requirements. However, in the relative scheme of things, critical care is still much under-valued. Consider that the work value of a simple cataract removal that can take 7-10 minutes to do, has a Medicare work value of 8.19, more than twice the 4.0 work value assigned to critical care.

No amount of HPI, ROS, medical, family or social history, or exam content is specified to support the claim for critical care; only that the chart supports the time the physician claimed was spent performing critical care and that the patient had the immediate potential for clinically significant deterioration.

This can be a subjective condition; the physician should describe concerns about the patient’s potential imminent decline.

CPT Time Analysis

CPT clarifies more of what is included in critical care time:

Time spent with the individual patient should be recorded in the patient’s record. The time that can be reported as critical care is the time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit. For example, time spent on the unit or at the nursing station on the floor reviewing test results or imaging studies, discussing the critically ill patient’s care with other medical staff or documenting critical care services in the medical record would be reported as critical care, even though it does not occur at the bedside. Also, when the patient is unable or clinically incompetent to participate in discussions, time spent on the floor or unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care, provided that the conversation bears directly on the management of the patient.

Time spent in activities that occur outside of the unit of off the floor (eg. telephone calls, whether taken at home, in the office, or elsewhere in the hospital) may not be reported as critical care since the physician is not immediately available to the patient. Time spent in activities that do not directly contribute to the treatment of the patient may not be reported as critical care, even if they are performed in the critical care unit (eg, participation in administrative meetings or telephone calls to discuss other patients). Time spent performing separately reportable procedures or services should not be included in the time reported as critical care time.
Code 99291 is used to report the first 30-74 minutes of critical care on a given date. It should be used only once per date even if the time spent by the physician is not continuous on that date. Critical care of less than 30 minutes total duration on a given date should be reported with the appropriate E/M code.

Code 99292 is used to report each additional 30 minutes beyond the first 74 minutes. It also may be used to report the final 15-30 minutes of critical care on a given date. Critical care of less than 15 minutes beyond the first 74 minutes or less than 15 minutes beyond the final 30 minutes is not reported separately.

Time flies when you are absorbed in your work and it is common that emergency physicians forget what commonly goes in to their care of the patient with the immediate potential for medical crisis. The following figure identifies several of these time-consuming critical care services.

CPT Time Analysis Chart and Examples

Medicare and CPT have provided exact instructions for how to count and report time. The first 30 – 74 minutes of critical care is to be reported using code 99291. Less than 30 minutes is to be reported with the appropriate E/M code. Each 30 minutes beyond 74 minutes is reported with an additional one-half hour code 99292.

Time spent when the physician is not immediately available to the patient does not count towards critical care, for example, phone calls from home/office, or radio command in the ED. Time spent performing other procedures that will be billed in addition to critical care and time spent by residents who are performing critical care are also not reportable.

Time is also defined specifically by date, not by 24-hour periods. In 1994, time in the CPT methodology was changed from “day” to “date” so that the critical care clock starts over at midnight .


Critical care started at 11:35pm with the episode continuing until 12:30am.

Report: Use an E/M service on first date of service because less than 30 minutes was performed on that date and report 99291 (First hour) on the second date of service.


Critical care started at 11:30pm with episode continuing until 12:30am.

Report: Report 99291 (First hour) on first date of service and 99291 (First hour) on the second date of service. Two different dates represent two different services.

Include in the chart a statement of the aggregate time of attention spent on the patient throughout their ED stay but discount the time spent performing separately reportable procedures. This time statement is an estimate. There is no precise proxy that can stand in place of your time of attention because critical care is mental work done when you are immediately available to the patient. Make a mental note of the time spent on procedures and deduct that time from your total attention to the patient.

Check the CPT manual to see exactly which procedures are bundled into critical care. They include only the following codes: 93561, 93562, 71010, 71015, 71020, 94760, 94761, 94762, 99090, 43752, 91105, 92953, 94656, 94657, 94660, 94662, 36000, 36410, 36415, 36600. These are all minor procedures, like reading a chest film, placing an NG tube, starting an IV, and ventilation management. Anything not listed above is separately billable, including EKGs and rhythm strip interpretations, which many payers wrongly try to bundle into to critical care payment.

Definition of “Critical”

The chart must meet two tests:

First, the condition of the patient must clearly involve a “high probability of sudden, clinically significant, or life threatening deterioration which requires the highest level of physician preparedness to intervene urgently” or unambiguously indicate an unstable medical condition or potential for life-threatening condition.

Second, the physician must actually intervene by providing “frequent personal assessment and manipulation”. The physician’s intervention must be documented. You should document performance of “direct personal management” as a form of intervention.

Documentation of Critical Care

Specifically, state your personal management of the patient during his/her critical period, by describing what the period involved. Write a sentence describing that the “high probability of _________ required my full and direct attention, intervention and personal management for ___ minutes while the patient was critical.”

The entire chart is necessary to support critical care time, as nursing assessment notes, procedure notes, medication rates and routes of administration, etc. substantiate the patient’s critical status. To fully support the claim for critical care the chart should note the time of both physician and nursing events (initial physician exam, re-exams, IV order times, dosage and medication changes.) The picture is clearer when both nursing and physician notes are available for review.

A good critical care procedure note would include comments about the patient’s progress throughout their ED stay, specific responses to each intervention as well as comments about multiple vital sign or exam assessments. Drug therapy start times, routes and rates of administration, along with the results of diagnostic tests and procedures should be clear in the chart. These are a means of supporting the patient’s clinical condition and help to reflect the time spent in the patient’s care.

Medicare’s documentation standard is the physician’s own note regarding total time spent in patient care. It is best to conclude critical care documentation with a ” procedure note” describing your activities and decision making while the patient was under your care. Note here how long pain lasted or vital signs were unstable, what was tried to alleviate it and at what time the patient no longer needed critical care attention.

By CPT’s definition, critical care is now clearly not an exclusive E/M service and can be billed in addition to an E/M service in some cases, because:

It has no history, exam or MD M component
Only E/M services of the same type must be combined on the same day.
CPT clearly does not bundle 9928x codes in with critical care.

Critical care and other E/M services may be provided to the same patient on the same date by the same physician… Any services performed which are not listed above should be reported separately.
(‘01 CPT, p. 18)

[An] emergency department code may be reported in addition to the critical care service code(s) if both services are provided by the same physician on the same day.
Medicare is more restrictive. Only when a patient receives an evaluation and management service first, then later in the same visit becomes critical, can you report both an E/M service and critical care on the same date of service.

Physicians should always note in the chart when critical care started after the initial evaluation.

Written by phil

June 8th, 2006 at 12:33 pm

Posted in Pearls


Written by phil

June 1st, 2006 at 11:49 pm

Posted in Residents