auditing critical care note-HELP!!!

adri3421

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Ok.....so Im auditing a critical care note.....and kind of second guessing myself.....would like to get some opinions as to whether or not this would support critical care charge: 99291? Pt was discharged the next day.......

HPI: headache, n/v much improved, tolerating reg diet

CT Head: Increased Subdural Hematoma

Assessment: Increased SDH secondary to initiation of anticoagulation therapy

Plan: Discussed at length with patient the increased risks secondary to her prosthetic heart valves, and worsening hemmorrhage with anticoagulants. Will initiate antiplatelet therapy.

Critical Care Time: 35 min
 
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Doesn't sound like it to me

While SDH may indeed result in a critically ill patient, and treatment of same may be critical care, this note is pretty "light."

I'm thinking that is why you are questioning it as well.

Is the patient in the ICU? Many physicians mistakenly believe that if a patient is in the ICU they should be coding critical care. Not true. A patient may be in the ICU because of need for intensive monitoring, but if the patient is stable the services provided may truly be a subsequent hospital visit.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

adri3421

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critical care note

Im thinking the physician is going to try to argue that the patient was in danger of life threatening deterioration due to "worsening state of the SDH" requiring intervention of changing to the antiplatelet therapy......how would you respond to that? The pt is in ICU.
 
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I would respond

I would respond that an auditor cannot read the physician's mind. If the physician believes the patient is in iminent danger of life-threatening deterioration then the physician should so specify in the documentation.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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