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Critical Care documentation

  1. #1
    Default Critical Care documentation
    Medical Coding Books
    If your physician documentatin everything else great to meet Critical Care but ended the note with

    Critical care time 50 minutes

    Would you give him credit for Critical Care services being that these are time based.

    Or do you look for a more through statement on how the exact time was spent?

    Daniel, CPC

  2. #2
    Milwaukee WI
    Default Huh?
    I don't want to seem like I am picking on you ... we all have our bad days. Or maybe you have a rogue auditor who is making life difficult for your practice.

    But you started off by saying the physician has documented everything else great to meet Critical Care . (emphasis added by FTB)

    What more do you want him to document? Do you expect the physician to repeat everything again after the Critical Care time spent statement?

    Maybe I'm misunderstanding your question. If so, please post a scrubbed note that concerns you.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    This is where I'm at.

    My intensivist document great.

    I can see in the history and assement plan that the patient meets the criteria for critical care, but naturally we need the time component.

    Some physician just put at the end of the note

    Critical Care time spent 55minutes.

    Some put
    CCT 65 min, serial exam, interaction with other MD, titration of therapies, family decision making, RN supervision.
    This patient has a high probability of sudden, clinically significant deterioration, which requires the highest level of physician preparedness to intervene urgently. I managed/supervised life or organ supporting interventions that require frequent physician assessment. I devoted my full attention to the direct care of this patient for the period of time which I have indicated. Time spent with family or surrogate(s) is included only if the patient was incapable of providing the necessary information or participating in the medical decision making. Time devoted to any procedures which I billed separately is not included.

    I think there both correct, but I'm hearing that the later statement I put is the way it should be.

    Your input.


  4. #4
    Milwaukee WI
    Default OKay I understand
    Okay, I see where you're going, Daniel.

    Personally, I think the second version is overkill. If the note itself clearly documents the patient's critical condition, and the critical care provided, there is no need to summarize.

    However ... I do think it is important to stipulate a few things in your "time " statement - that this was direct face-to-face critical care, that the time spent was at least 30 minutes, and that the time spent is EXclusive of any procedures performed. Frequently (especially the first day) you have CVLs place, chest tubes, intubation, CPR etc. Time spent on such bedside procedures cannot be counted as part of critical care.

    F Tessa Bartels, CPC, CEMC

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