Wiki Critical care

[Cristy]

I bill for a physician.

I'm extremely new at coding and need serious help with coding hospital matters. Doc sees a patient and the patient goes downhill, doc spends an hour and 48 minutes of critical care with this patient. Doc devotes his times specifically to this patient and is making arrangements with family, other doctors and hospitals and has this patient life flighted out. His discharge paperwork goes into great detail of intubation, etc....HOWEVER....I have been strictly warned by individuals that you can not for any reason code critical care unless he actually writes, "I spent "X" amount of time of critical care on this patient".
Is this correct?
Is he able to go back to his summary and add the actual time spent?....or is it chalked up to lesson learned and just move on?
(Doc keeps a PDA with him to keep up with his patients...that is where he put the actual time (and knew it was 1 hour 48 minutes)but I explain to him that that had nothing to do with the summary reports he submitted)
Please help......I would greatly appreciate ANY assistance.

Thanks,
Cristy

 

[LLovett]

Time must be documented in the note. If he has record of it elsewhere I see no reason why he couldn't addend the note to include time.

Just my opinion,

Laura, CPC

 

[FTessaBartels]

Time must be on the note

Yes, the time and the fact that it was spent in direct critical care (EXCLUSIVE of procedure! ... you can bill the intubation separately), must be on the critical care note.

If he has this time documented in his PDA, by all means have him go back to the hospital record and add this information, or if it is a dictation that is already electronically signed, have him dictate and addendum.

One hour 48 minutes of critical care time (108 min) is significant.

F Tessa Bartels, CPC, CEMC

 

[Cristy]

Thank you so very much for your help!!!