Critical care visit requires chief complaint??

tobieforte

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New Orleans, La
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I have a physician that sees a hospital patient and lists his time to bill critical care, but he does not give a chief complaint. If this permitted for critical care since it time driven?
 

colsonccsp@yahoo.com

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Houston, TX
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If your physician is providing critical care to the patient the chief compliant should be obvious from the documentation. Meaning that critical care is only founded when the patient is in dire straits aka an organ is failing and there is life threatening deterioration. In addition to the time critical care is provided your provider should document what organ system is failing and/or why critical care is necessary, this is where I would look for the chief complaint.

The official definition from CMS is "direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition." MCPM Chapter 12 section 30.6.12
 
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