Wiki Can you charge Critical Care WITHOUT Time Noted?

[sjasontaylor77]

Probably a stupid question but just wondering. If there is no time mentioned but Critical care is noted, 1) would you just default to a 99291, or can you not code any critical care without the time? 2) Can a provider append their note and add the time after the fact?

I had a hard time trying to find something online about this.

Thanks!

 

[Cmama12]

Hi, you definitely need to have the time stated in the note in order to use a crit care code and yes, they can add time after, although I don't know if there is a deadline for that.

 

[jkyles]

Probably a stupid question but just wondering. If there is no time mentioned but Critical care is noted, 1) would you just default to a 99291, or can you not code any critical care without the time? 2) Can a provider append their note and add the time after the fact?

I had a hard time trying to find something online about this.

Thanks!

Hi there, please review the guidelines in the CPT manual. They clearly state that the provider must document time.

Correcting a note might be an option, but the provider will need to follow the carrier's rules or guidelines. Here are the guidelines from Noridian, but check with your own MAC. https://med.noridianmedicare.com/web/jeb/cert-reviews/mr/documentation-guidelines-for-amended-records

Sometimes providers' mistakes are "teachable moments."