Correct documentation for Critical Care is crucial especially in the event of an audit. If Critical Care is not established in the documentation the visit will be downcoded.
According to the CPT guidelines critical care is defined as "...critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patients condition;" critical intervention involving “…high complexity decision making to assess, manipulate, and support vital organ system failure;” and, time, defined as “…time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit.” In order for critical care services to be coded and billed, documentation to support all three components of the definition (severity of the illness, the care provided and the amount of time) must be present in the medical record, accompanied by the physician’s attestation that critical care was provided.
A simple statment from your providers saying the patient's condition is serious would not establish that this patient is critical if that is all that they are documenting. Their documentation should include a statement covering the nature of the illness and show the medical necessity of the critical care. Also they must the total time spent in critical care as anything under 30 minutes cannot be billed as critical care.
Our doctors are instructed to document the condition and the reason the patient is considered critical and what they have done to provide the critical care along with the time spent in providing critical care.
There are links out there that discuss what is required - here are a couple that I found that discusses what is needed:
Hope this helps.
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