The patient must be critically ill. The care provided must be critical care. The direct face-to-face time (includes floor/unit time if patient is hospitalized) must be documented and must be at least 30 minutes.
Most of our intensivists dictate a two-page single spaced note that is very detailed and includes a statement as to the critical nature of the patient's condition.
But, a physician might be able to document critical care in a couple of sentences. As long as the documentation is clear as to the patient's condition and that at least 30 minutes of direct critical care was provdied.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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