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Is it ethical to bill for CPR?

Dr K K Aggarwal

Honorary Secretary General IMA

1.      If a person has been brought dead, we do not need to do resuscitation. Death means signs of rigor mortis or livor mortis present.

2.      Rigor mortis (Latin: rigor "stiffness", mortis "of death") is one of the recognizable signs of death, caused by chemical changes in the muscles after death, causing the limbs of the corpse to stiffen. Rigor mortis occurs three to four hours after death.

3.      Livor mortis (Latinlivor—"bluish color," mortis—"of death"), post mortem lividity (Latin: postmortem—"after death", lividity—"black and blue"), hypostasis (Greekhypo, meaning "under, beneath"; stasis, meaning "a standing) or suggillation, is one of the signs of death. Livor mortis is a settling of the blood in the lower (dependent) portion of the body, causing a purplish red discoloration of the skin. When the heart stops functioning and is no longer agitating the blood, heavy red blood cells sink through the serum by action of gravity. Livor mortis starts in 20–30 minutes. Then color becomes purplish red in next 1–3 hours. Size of patches increase in next 3–6 hours. Maximum lividity occurs within 6–12 hours

4.       Decapitation of the head, total decomposition of the body, post mortem stiffness, post mortem lividity and burned beyond recognition are easy to remember death situations.  

5.      If a person is brought in cardiac arrest (no signs of rigor or livor mortis) CPR ( BCLS or ACLS) is the standard care.

6.      Cardiac arrests are often referred to as "witnessed" or "unwitnessed" events. A cardiac arrest is called unwitnessed if the patient is found without a pulse and no one was present at the time the patient collapsed. 

7.      A witnessed cardiac arrest is when someone saw him alive during last breath and since them was with the victim

8.      All witnessed cardiac arrest needs standard CPR ( both BCLS and ACLS)

9.      Unwitnessed cardiac arrest in absence of rigor or livor mortis also require standard CPR ( both BCLS and ACLS)

10.  Resuscitation needs to be done for minimum 30 minutes in unwitnessed cardiac arrest and longer in witnessed cardiac arrest.

11.  In hypothermia deaths, CPR is successful even after hours of cardiac arrest. The dictum is nobody is dead unless warm and dead.

12.  It is normal to charge for CPR as per hospital standard rates along with the cost of the consumables.

13.  Charges for patients with out of hospital cardiac arrest are substantial, even among patients that do not survive to hospital admission. Treatment with therapeutic hypothermia is associated with better outcomes, more procedures, and higher charges. [Resuscitation. 2012 Oct; 83(10):1265-70.]

14.   Basic CPR: involves the provision of cardiac life support including chest compressions and ventilation of the patient. Basic CPR consists of assessing the victim, opening the airway, restoring breathing (e.g., mouth-to-mouth, bag-valve-mask, etc.), and restoring circulation (e.g., closed chest cardiac massage). Bag valve mask is a disposable device.

15.   Advanced CPR:  involves IV line insertion periphery or central, drug therapy and possibly defibrillation. CPR is performed prior to, with continuation during, advanced life support interventions, e.g., drug therapy and defibrillation.  It may also requires use of external pace makers, emergency angiography, stenting etc.

16.   Timings of CPR is often coded as less than 30 minutes, 30-75 minutes and More than 75 minutes.

17.  Billable items are for Basic CPR, Advanced CPR, Difficult IV line, Central Line, External pacemaker, Defibrillation, Internal pacemaker, Rescue angiography and stenting, Drugs and disposables, Intra-aortic balloon pump, Cardiologist fee, Anaesthetist Fee, Intensivist fee