Critical Care time by the ER Physician

TMarlow

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Fort Walton Beach
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Ok, I will start out by saying... I have always asked the ER physician for the CC time spent treating the patient, in order to accurately charge CC 99291. I am now being told that the physician isn't required to document the time and that with sufficient nursing documentation I can make that decision. Per the cpt book, his/her time is to be documented in the record. Has this rule changed?? HELP!!:eek:
 

jimbo1231

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Brooklyn, New York
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No

Guidelines haven't changed. CC time must be documented by the physician. Several elements besides pure bed side time can be counted toward the minimum of 30 minutes including consulting with specialists, medical record documentation etc,and separately billable services such as Endotracheal intubation time must be subtracted. But nurses can't document physician CC services.

Jim
 
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See Medicare Claims Processing Manual Chapter 12 section 30.6.12.E - "the physician's progress note(s) shall document the total time that critical care services were provided."
 
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