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------------------------------------------------ ICU - CC: Multi-system organ failure

INTERVAL HISTORY:
Patient remains intubated and sedated. Overnight events reviewed. Tolerating tube feeds. Systolic pressures have been running in the low 90s on LEVOPHED. Cultures remain negative. Kidney function has worsened, but patient remains non-oliguric.

PHYSICAL EXAM:
BP 96/60, Pulse 112, Temp 100.8. Lungs have anterior rhonchi. Heart RRR with no MRGs. Abdomen is soft with positive bowel sounds. Extremities show moderate edema.

LABS:
BUN 89, creatinine 2.6, HGB 10.2, WBC 22,000. ABG: 7.34/100/42 on 50% FiO2. CXR shows RLL infiltrate.

IMPRESSION:
- Hypoxic respiratory failure
- Community acquired pneumonia
- Septic shock
- Non-oliguric acute renal failure

PLAN:
- Continue NS at 75 cc/hr.
- Decrease ZOSYN to 2.25 grams IV Q 6H
- Follow cultures.
- Continue tube feeds.
- Titrate LEVOPHED to maintain SBP > 90
- Usual labs ordered for tomorrow.
- Critical care time: 35 minutes

What CPT® code(s) is/are reported?
a. 99233
b. 99232
c. 99291, 99292
d. 9929

The CPT® codes that should be reported in the scenario given where a patient is experiencing multi-system organ failure, remains intubated and sedated with a history of hypoxic respiratory failure, and septic shock, and is receiving critical care time of 35 minutes are 99291 and 99292. Code 99291 is used for the first 30-74 minutes of critical care on a given date, and it is appropriate here as the critical care time is 35 minutes. If the critical care time had extended beyond 74 minutes, code 99292 would be used for each additional 30 minutes. However, as the critical care time reported is 35 minutes, only code 99291 is necessary.