Wiki Critical Care Audit Question

[christinav]

I am currently auditing Critical Care Services and there is a physician who provides the EHR signed document that does not indicate that it is a Critical Care document, but will then Write using a normal pen on the bottom of the last page stating the total time spent providing critical care services. Would this validate the use of Critical Care billed services? The provider does not initial the area that he wrote on the document or provide an addendum on the document. It just looks like he printed the document then later wrote in the total time spent.

I don't think that this validates, but just need some clarification and input please?

Thank you
Christina

 

[kroemer4]

Critical Care Documentation

That sounds like an awkward way of documenting from the physician's perspective! I realize not the intent of the original question, but what does he do with the handwritten document after printing and notating? Does it get scanned back into the record?

Otherwise, this site includes appropriate documentation practices for critical care coding: https://acphospitalist.org/archives/2010/03/coding.htm. From the compliance perspective, credit for critical care services would not be appropriate based on your example of the documentation.

 

[coloradopa]

I am currently auditing Critical Care Services and there is a physician who provides the EHR signed document that does not indicate that it is a Critical Care document, but will then Write using a normal pen on the bottom of the last page stating the total time spent providing critical care services. Would this validate the use of Critical Care billed services? The provider does not initial the area that he wrote on the document or provide an addendum on the document. It just looks like he printed the document then later wrote in the total time spent.

I don't think that this validates, but just need some clarification and input please?

Thank you
Christina

Most likely this wouldn't work. It depends on what is in the EHR document.
Generally we require four things for a critical care bill:
A statement the patient is critically ill
The organ systems affected
What the provider has done to support those organ systems
Time spent in critical care (ideally a statement saying this does not include procedural time)

Based on what you wrote this does not meet documentation criteria for critical care billing.

Here is an article on critical care billing
http://www.sccm.org/Communications/...Billing-Basics-Billing-for-Critical-Care.aspx