Category: Critical Care
Posted: 5/5/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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New Perspectives on Clostridium difficile
Janka J, O'Grady NP. Clostridium difficile infection: current perspectives. Curr Opin Crit Care 2009;15:149-53.
Category: Critical Care
Posted: 4/28/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Acute Cor Pulmonale and Ventilation In the critically ill,
Acute cor pulmonale (ACP) is usually observed in the setting of massive pulmonary embolism or acute respiratory distress syndrome (ARDS). As we manage more and more critically ill patients in the ED, it is likely that you will manage patients who develop ARDS.
We have discussed in previous pearls that, especially in ARDS, using a low tidal volume and monitoring plateau pressure are key components to mechanical ventilation.
For patients with ARDS who develop ACP, consider lower plateau pressure thresholds (< 26 cm H20) and minimizing PEEP to < 8 cm H2O.
If ACP persists despite lower plateau pressures and low PEEP, consider prone position ventilation as a last resort.
Jardin F, Vieilllard-Baron A. Acute cor pulmonale. Curr Opin Crit Care 2009;15:67-70.
Category: Critical Care
Posted: 4/21/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Assessing Volume Status in the Critically Ill
Boyd JH, Walley KR. The role of echocardiography in hemodynamic monitoring. Curr Opin Crit Care 2009;15:1-5.
Category: Critical Care
Posted: 4/14/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Mechanical Ventilation and Obesity
Lapinsky SE, Posadas-Calleja JG, McCullagh I. Clinical review: Ventilatory strategies for obstetric, brain-injured, and obese patients. Crit Care 2009;13:206.
Category: Critical Care
Posted: 4/7/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Ventilation in the Brain-injured Patient
Lapinsky SE, Posadas-Calleja JG, Mcullagh I. Clinical review: Ventilatory strategies for obstetric, brain-injured, and obese patients. Crit Care 2009;13:206-13.
Category: Critical Care
Posted: 3/31/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Mechanical Ventilation of the Obstetric Patient
Lapinsky SE, Posadas-Calleja JG, McCullagh I. Clinical review: Ventilator strategies for obstetric, brain-injured, and obese patients. Crit Care 2009;13:206.
Category: Critical Care
Posted: 3/24/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Critical Illness-Related Corticosteroid Insufficiency (CIRCI)
So, which critically ill patients do you treat with steroids? Current literature suggests the indications for steroid treatment include vasopressor dependent septic shock and persistent ARDS despite supportive therapy and lung protective ventilation. A patient who requires only an hour or two of a vasopressor while being fluid resuscitated is unlikely to benefit. An accepted dosing schedule is hydrocortisone 50 mg IV every 6 hours.
Marik PE. Critical illness-related corticosteroid insufficiency. Chest 2009;135:181-93.
Category: Critical Care
Posted: 3/17/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Early Critical Care Management of Aneurysmal SAH
Diringer MN. Managment of aneurysmal subarachnoid hemorrhage. Crit Care Med 2009;37:432-40.
Category: Critical Care
Posted: 3/3/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Neuromuscular Blocking Agent (NMBA)
Category: Critical Care
Posted: 2/24/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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The Crashing Intubated ED Patient
Category: Critical Care
Posted: 2/17/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Sepsis in Pregnancy
Guinn DA, Abel DE, Tomlinson MW. Early goal directed therapy for sepsis during pregnancy. Obstet Gynecol Clin N Am 2007;34:459-79.
Category: Critical Care
Keywords: ventilator associated pneumonia, head of bed (PubMed Search)
Posted: 2/10/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Ventilator Associated Pneumonia (VAP)
Category: Critical Care
Keywords: sedation, analgesia, mechanical ventilation (PubMed Search)
Posted: 2/3/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Sedation and Analgesia in Mechanical Ventilation
Category: Critical Care
Keywords: pneumonia, sepsis, severe sepsis, septic shock, mrsa, vancomycin (PubMed Search)
Posted: 1/28/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Pneumonia and Sepsis
Category: Critical Care
Keywords: anaphylaxis, urticaria, angioedema, shock (PubMed Search)
Posted: 1/20/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Clinical Manifestations of Anaphylaxis
Winters ME. Anaphylaxis. In: Field JM (ed) The Textbook of Emergency Cardiovascular Care and CPR. Philadelphia, Lippincott Williams & Wilkins, 2009:530-7.
Category: Critical Care
Keywords: sepsis, mechanical ventilation, oxygen delivery (PubMed Search)
Posted: 1/13/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Sepsis and Mechanical Ventilation
Category: Critical Care
Keywords: intracerebral hemorrhage, normal saline, hypertonic saline (PubMed Search)
Posted: 1/7/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Intracerebral hemorrhage and fluid management
Rincon F, Mayer SA. Clinical review: critical care management of spontaneous intracerebral hemorrhage. Crit Care 2008;12:237.
Category: Critical Care
Keywords: blood pressure, intracerebral hemorrhage (PubMed Search)
Posted: 12/31/2008 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Blood Pressure Control in ICH
Rincon F, Mayer SA. Clinical review: critical care management of spontaneous intracerebral hemorrhage. Crit Care 2008;12:237.
Category: Critical Care
Keywords: renal replacement therapy, hemofiltration (PubMed Search)
Posted: 12/23/2008 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Hemofiltration
Category: Critical Care
Keywords: Critical Care, reimburshment, billing (PubMed Search)
Posted: 12/20/2008 by Michael Bond, MD
(Updated: 2/18/2025)
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Critical Care Billing Pearls:
Level | RVU | Medicare | Commerical |
99285 ED E/M, Level 5 | 4.71 | $170 | $304 |
99291 Critical Care, first hour | 5.84 | $211 | $363 |
As the table shows Critical Care billing will earn you approximately 25% more with no additional overhead. Critical care time must be at least 30 minutes, and the following procedures are included in the critical care code:
The following procedures are not bundled into critical care time, so they can be billed separately, therefore the time you spend doing these procedures can not be included in your total critical care time:
Remember critical care time does not need to be continuous but you need to be immediately available to the patient for the time to count. You can not count time going off the floor to review an xray or CT, but this time can be counted if you do it in the immediate vacinity of the patient.
FINAL CAVEAT To help your coders bill appropriately it helps to include a statement such as "Critical Care time XX minutes where I was directly involved in the care of this patient exclusive of all other separately billable procedures."
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