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Critical Care

  1. #1
    Default Critical Care
    Medical Coding Books
    I'm auditing a record that's originally billed as a critical care 99291. The time in not noted in the actual notes but on the physician's billing sheet only. Time stated is: Crit. Care Time 35 min.

    Is this appropriate?
    Karen, CPC
    Physician Chart Auditor

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default No
    Not documented, not done.

    The billing sheet is NOT part of the medical record. The documentation of the service MUST include the time spent providing direct critical care to the patient (and must be 30 minutes or more).

    Given that the physician included the time on the billing sheet, I would accept an addendum to the original dictation specifying the time.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Default
    Quote Originally Posted by FTessaBartels View Post
    Not documented, not done.

    The billing sheet is NOT part of the medical record. The documentation of the service MUST include the time spent providing direct critical care to the patient (and must be 30 minutes or more).

    Given that the physician included the time on the billing sheet, I would accept an addendum to the original dictation specifying the time.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC
    Thanks Tessa
    Karen, CPC
    Physician Chart Auditor

  4. #4
    Default Narrative
    I agree with that, but have another question to pose: is anyone else putting total critical care time on the claim form as a narrative to support their coding? I was recently in a McVey teleconference that recommended it. Does anyone else see requests for medical records frequently for critical care?

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