You must have face-to-face time (30 minutes or more) spent providing critical care to the critically ill patient in order to code 99291-99292.
I see a critically ill patient. If there were time noted and some expansion on the cares given I'd agree with critical care code. But you've already mentioned there is no time noted.
We educate our physicians to document as follows: "I spent xx minutes providing critical care to this critically ill patient, exclusive of procedures."
If physician cannot (or will not) amend the record to note time spent in critical care, then I'd be inclined to code the discharge day management 99238 (again no time so you can't code 99239).
F Tessa Bartels, CPC, CEMC
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join