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Wiki Critical Care documentation

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rkingCPMA

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Provider is charging critical care cpt code 99291. Although time is documented, I'm not sure that this stand alone note clearly supports critical care services. Do you agree or disagree?

Pt seen in ICU
Sedated (given Ativan in ECC)
Extemely weak
NAD but appears ill
VS tachy @ 110s
BP sl high
Lungs clear
Abd soft NT
Neuro Non focal
Labs reviewed
IV k, PO4, Mg ordered
Serum Acetone, UA ordered
Ethylene glycol, methanol level pos
Discussed with dtrs at length Re:
Condition, Dx, prognosis, POC.
CCT spent 30 min.

All feedback/guidance is appreciated!
 
You are correct. There is no critical care given.
Sue Jordan, CPC, CGSC, CHONC
St. Paul Chapter Vice President
 
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