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Critical Care documentation?

  1. #1
    Nassau County
    Default Critical Care documentation?
    Medical Coding Books
    I am currently reviewing a previous audit and need assistance with CC documentation guidelines - I know the total time spent rendering CC svcs to a patient must be documented, but, is the physician required to document the start & end times for the care? Any help will be greatly appreciated.

  2. #2
    It is not required to have a start and end time. It is required to have the total time. For me its hard enough to get my drs to give the total time, I am not willing to ask for anything more

  3. #3
    Nassau County
    Thank you. Now all I have to do is learn how to translate scribble into adequate documentation!

  4. #4
    Remember that critical care involves impairment to "one or more vital organ systems". I usually start by looking for some sign that they are on a ventilator. Next I try to decifer if Renal or Liver failure exists, if the physician documented labs these numbers should back that up. Also the blood pressure numbers are probably in the documentation if they are off the chart high or low go with it. For me it is easier to read the numbers first and then I at least have an idea what words might pulled out of the scribble. Good luck!

  5. Default Critical Care
    A question has come up regarding Critical Care and I need some additional help. Does CC end with death, or can it continue as the physician finishes all paperwork. I have always believed that it would end with death. I have a physician who is questioning this. I can not find documentation that specifically states that it would end at the death of the patient.
    Does anyone have a link to documentation that can help with this matter

  6. #6
    Nassau County
    Question Thanks!
    First off, thanks for all who responded to my inquiry. I will definitely use your advice.

    As for CC ending in death; the answer is no. A good example would be a patient who has suffered heart failure - they might very well be in CC for hours or days but can still recover. That time while critical is billable as CC.

    Now I have an additional CC issue - if an MD bills a 99291 and 99292 what kind of documentation is required to prove that the MD did actually spend all of that time just in the care of that patient?

  7. #7
    Nassau County
    Default Re-response to Lynn R
    Sorry Lynn, after reading your question again I realized that you were not asking if CC has to end in death, the question was does it end in death. I will research that further for you but I believe a D/C code comes into play somewhere.....

  8. #8
    Usually all our docs say is total critical care time at bedside with patient or if they are interviewing family members/conferring with other providers they will document.
    Pat A. Trautner, CCS/CPC/CEDC/CHONC

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