Trendale
Guru
Hello
I am coding for a pulminary specialist and sometimes he see patients in the critical care unit. After reading the guidelines and critera for these codes, it is to my understanding the doctor needs to document that he spent X amount of time in the critical care unit. Also the patient has to have high risk condition or life threatnening. Please let me know if I should be aware of any other critera that should be documented.
My problem that I am having is that this physcian turns in a face sheet with all the patients he see each day, next to the names of these patients, he writes what service he performs, for example if he saw the patient in critical care, he would write CC1H indicating he saw the patient in CC for 1 hr, or sometimes he does not state in his note that he saw the patient in CC for X amount of time.
When he does state it, he would say" thank you for allowing me to see this patient in consultation, crital care 1 hour." I think that this is sufficient, please let me no otherwise. Also when he does not state it, I am thinking he must assume because the patient's room number with a C indicating critical care is at the top of the note by the patients name, and the fact that he writes it on the face sheet that this is suffice. Please let me know if the room number indicating the patient is in cc is suffice, I don't think it is, I just want to clear it up with the doc.
Also if the doctor sees the patient in CC subsequently, and he does a handwritten note that states he saw the patient in CC for X amount of time, is this OK? If he does not state it, I should code this as a subsequent right?
Sometimes on his handwriiten note however, he would write at the top of the note "pulmonary/CCM." In the body of the note, it does not indicate that he saw the patient in CCU, nor does it states a time. I am thinking again, he is assuming because he wrote pulmonary/CCM that this is suffice.
I'm sorry one more thing,
Someone told me today, that the start and stop time shoud be documented. Is this true? I thought if the total time is documented, this would be sufficient. I know this is true for discharge patients, but I don't recall seeing this in the guidelines for CC.
I don't code crital care that often, in fact it's been awhile, so I had to refresh by reading the guidelines, so please let me know if there is anything thing else I should know. Thanks!
I am coding for a pulminary specialist and sometimes he see patients in the critical care unit. After reading the guidelines and critera for these codes, it is to my understanding the doctor needs to document that he spent X amount of time in the critical care unit. Also the patient has to have high risk condition or life threatnening. Please let me know if I should be aware of any other critera that should be documented.
My problem that I am having is that this physcian turns in a face sheet with all the patients he see each day, next to the names of these patients, he writes what service he performs, for example if he saw the patient in critical care, he would write CC1H indicating he saw the patient in CC for 1 hr, or sometimes he does not state in his note that he saw the patient in CC for X amount of time.
When he does state it, he would say" thank you for allowing me to see this patient in consultation, crital care 1 hour." I think that this is sufficient, please let me no otherwise. Also when he does not state it, I am thinking he must assume because the patient's room number with a C indicating critical care is at the top of the note by the patients name, and the fact that he writes it on the face sheet that this is suffice. Please let me know if the room number indicating the patient is in cc is suffice, I don't think it is, I just want to clear it up with the doc.
Also if the doctor sees the patient in CC subsequently, and he does a handwritten note that states he saw the patient in CC for X amount of time, is this OK? If he does not state it, I should code this as a subsequent right?
Sometimes on his handwriiten note however, he would write at the top of the note "pulmonary/CCM." In the body of the note, it does not indicate that he saw the patient in CCU, nor does it states a time. I am thinking again, he is assuming because he wrote pulmonary/CCM that this is suffice.
I'm sorry one more thing,
Someone told me today, that the start and stop time shoud be documented. Is this true? I thought if the total time is documented, this would be sufficient. I know this is true for discharge patients, but I don't recall seeing this in the guidelines for CC.
I don't code crital care that often, in fact it's been awhile, so I had to refresh by reading the guidelines, so please let me know if there is anything thing else I should know. Thanks!