Critical Care Documentation Essentials

Critical Care Documentation Essentials

Critical Care services (99291-99292) are time-based, and improper documentation of time is a frequent reason that payers deny payment for these services. Educating providers to document time appropriately will help to maximize reimbursement and reduce additional documentation requests (ADRs).

The American Medical Association (AMA) defines critical care as the direct delivery by a physician(s) or other qualified healthcare professional of medical care for a critically ill or critically injured patient. A critical illness or injury is further defined as an impairment of one or more vital organ systems, with imminent or threatening deterioration in the patient’s condition.

Code 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes reports the first 30-74 minutes of care; while 99292 …each additional 30 minutes (List separately in addition to code for primary service) reports additional blocks of time in 30-minute increments beyond the first 74 minutes. These codes are reported once per calendar day.

To appropriately claim 99291 and 99292, the critical care note must specify the total duration of critical care time spent with the patient. The time must be explicit, and should include the verbiage “minutes.” The total time should include all time spent engaged in work directly related to the patient’s care, whether that time was at the immediate bedside, or elsewhere on the floor. The time spent does not have to be continuous, but the time cannot be the same for each critically ill/injured patient, nor can it be a span (e.g., “I spent two to three hours with the patient”).

CPT® guidelines explain that time spent on activities that do not directly contribute to the treatment of the patient, or time spent performing separate reportable procedures or services, should not be included in the time reported as critical care time. CPT® guidelines require that the reporting provider must devote his or her full attention to the patient during the time specified as critical care, and therefore cannot provide services to any other patient during the same time.

Documentation must be specific to the patient. In the age of electronic medical records, it is imperative the physician avoid cloned notes.

As an example of proper documentation of critical care services, the physician might specify, “I spent 180 minutes of critical care time excluding the procedure time. I reviewed lab work, changed the patient’s medication, and coordinated protocol in the event of tachycardia or desaturation.”

As an alternative to documenting total critical care time, the provider may document start and stop times. When doing so, the provider must be careful not to count critical care time for any services not directly related to care of the critical patient. For instance, if the provider signs a lab order for a different patient during the start and stop time of providing critical care, the time spent reviewing and signing the lab order cannot count toward the critical care time for the critically ill/injured patient, even if the individual is on the floor.

Time cannot be the same for each critically ill patient. Critical care patients are occasionally “critical” day after day. Additionally, a patient may be stable and still meet the requirements for critical care. Therefore, documentation should focus on what transpired from the last time the patient was seen until the present; listing all circumstances that emerged that effect the current plan of care. Have your physician ask himself or herself the following, and document the answers: What happened since I left the patient last? Why am I changing the plan of care? If I did not modify the plan of care, what are the potential outcomes?

For example, the physician may document, “Over the past 24 hours, the patient has become resistant to the antibiotic per the lab work performed yesterday. The plan is to perform a thoracentesis and send the results for further testing. In the meantime, start XYZ to minimize further complications…”

The plan should always include the patient’s status. This should be detailed enough to support that critical care visit and continued critical care visits, as necessary. Examples include but are not limited to: the patient is worsening, unchanged, improved, remains critical, poor prognosis, stable but remains critical, stable but remains unchanged, and any other clarity which can be provided at the time.

For example, “The patient is stable but remains critical at this time. Taper IV antibiotics and prepare for extubation over the next few days.”

Critical care notes do not have specific bulleted items; therefore, it is imperative the documentation contain enough information to distinguish critical care from other E/M services.

Silvermoon Taggart

Silvermoon Whitewater Taggart, MBA, CPC, AAPC Fellow is Practice Administrator at Pulmonary and Internal Medicine Associates, Inc., a nine provider practice in Stuart, Fla.

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Silvermoon Whitewater Taggart, MBA, CPC, AAPC Fellow is Practice Administrator at Pulmonary and Internal Medicine Associates, Inc., a nine provider practice in Stuart, Fla.

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