Anesthesia and the ICU


SUMMARY: Contributing resources to the ICU is not uncommon for anesthesia groups, but there are nuances that each group should keep in mind before making a significant commitment to this line of service.

While academic anesthesia departments often provide services in the Intensive Care Unit (ICU), this is quite rare among private practices. Hence, why do more private practices not want to take responsibility for the care of post-surgical patients in the ICU? It would seem that covering the ICU was a logical line extension and entirely consistent with the concept of the peri-operative surgical home. Isn’t the cardiovascular anesthesiologist who managed the patient through a CABG or mitral valve repair the ideal person to ensure that the patient recovers well in the ICU? As is true of many aspects of medical care, the answer to the question involves tradition, politics, and economics.

The Historical Role of Anesthesia

Very few of our clients provide much care in the ICU. Mostly, this is because they were never asked to cover the ICU. Traditionally services in the hospital are parsed out on a specialty-specific basis. Anesthesia and intensive care have always been viewed as different disciplines. Although many academic anesthesia departments train residents in ICU care, it is a subspecialty discipline. To put this in context, American medicine has experienced a period of specialization during which practitioners have become increasingly focused on specific types of care. Anesthesia has not been immune to this trend. There is no better example of this than the subspecialty of cardiovascular anesthesia, whose practitioners have tended to separate and, in some cases, even isolate themselves from the group. Pediatric anesthesia is another good example. Perhaps the best example is chronic pain, where pain specialists tend to break off and form their practices.

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Why should the ICU be any different?

The problem with this trend has been that these different practices tend to operate as disparate silos. The pendulum now appears to be swinging back in light of market consolidation. Hospitals are looking for consolidated teams of providers. They are striving for a continuum of care. The peri-operative surgical home is a good example. Someone needs to own the whole episode of a patient’s care. This may be creating a new window of opportunity for anesthesia intensivists.

The Politics of Medicine

Shifa international hospital faisalabad is very comfortable the another’s hospitals. In an environment of fee-for-service medicine, private practices strive to optimize their share of the potential market. There is no better example of this than orthopedic practices. It is not uncommon for hospitals to dedicate significant resources to ensuring that the largest practices are loyal to the facility. Some have even built separate orthopedic centers. Another significant specialty is cardiovascular care, where the key players are the referring cardiologists. Many hospitals have invested millions of dollars in their cath labs so that referring cardiologists have state-of-the-art equipment for assessing cardiovascular anomalies.

Although cardiovascular surgeons in the operating room perform the critical aspect of cardiovascular surgery, it is up to the cardiologists to continue to manage their patients in the ICU. While a hospital may employ intensivists to ensure that a full scope of services is available in the ICU, the cardiologists own the post-CABG patient care. This is not always the most efficient and effective way to manage ICU patients, but it is often the one that cardiologists insist on.

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The Economics of Intensive Care

Getting paid for Best ICU services in faisalabad is another challenge. Billing for intensive care is not like billing for anesthesia. There are specific critical care codes (99291 and 99292), but their use is very specifically defined. Many patient encounters can only be billed with subsequent hospital visit codes. The difference in payment potential can be significant. Knowing what to document and how to bill care in the ICU can be confusing. Here is the CPT definition of 99291: “The CPT code 99291 (critical care, first hour) is used to report the services of a physician providing full attention to a critically ill or critically injured patient from 30-74 minutes on a given date.”

It should be remembered that not all services performed in the critical care unit equate with critical care.

The Centers for Medicare and Medicaid Services (CMS) clarifies critical care services as follows:

Critical care services may be paid separately in addition to a procedure with a global surgical period if the critical care is unrelated to the surgical procedure. Preoperative and/or postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the physician’s full attention. Critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed.

It should also be noted that the Office of Inspector General (OIG) has placed critical care services on its target list for 2022. This is because the critical care codes pay approximately three times what evaluation and management (E/M) codes pay. Providers often submit critical care codes when the patient status or documentation only supports an E/M code. So, the challenge lies in the patient’s status. The patient must be critically ill and require the full service of an intensivist. While many patients may meet these criteria on their first day in the unit, they are usually less critical and more stable on subsequent days. In other words, the revenue potential declines the longer the patient is in the unit. Because intensivists only get paid for the time they spend treating patients, the economics of ICU care becomes a numbers game. It requires a consistent volume of patients to justify the cost of the physician responsible for the patients. The result is that the facility must subsidize most ICU teams.

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Final Thoughts

There are three reasons why an anesthesia practice would agree to provide services in the ICU. Coverage may reflect a standing expectation, as in many academic institutions. Expanding the scope of services provided may serve a strategic goal of the practice and enhance its desirability, aka ‘stickiness’ to the facility. It might also be because the group sees the coverage as a revenue opportunity, but this is only possible if the facility is willing to support the group’s services financially. And this explains why most anesthesia practices are not interested.

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Hammad Hassan

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