# Critical care coding



## Trendale (Jun 2, 2009)

Hello 
I am coding for a pulminary specialist and sometimes he see patients in the critical care unit. After reading the guidelines and critera for these codes, it is to my understanding the doctor needs to document that he spent X amount of time in the critical care unit. Also the patient has to have high risk condition or life threatnening. Please let me know if I should be aware of any other critera that should be documented.

My problem that I  am having is that this physcian turns in a face sheet with all the patients he see each day, next to the names of these patients, he writes what service he performs, for example if he saw the patient in critical care, he would write CC1H indicating he saw the patient in CC for 1 hr, or sometimes he does not state in his note that he saw the patient in CC for X amount of time.
When he does state  it, he would say" thank you for allowing me to see this patient in consultation, crital care 1 hour." I think that this is sufficient, please let me no otherwise. Also when he does not state it, I am thinking he must assume because the patient's room number with a C indicating critical care is at the top of the note by the patients name,  and the fact that he writes it on the face sheet that this is suffice. Please let me know if the room number indicating the patient is in cc is suffice, I don't think it is, I just want to clear it up with the doc.

Also if the doctor sees the patient in CC subsequently, and he does a handwritten note that states he saw the patient in CC for X amount of time, is this OK? If he does not state it, I should code this as a subsequent right?
Sometimes on his handwriiten note however, he would write at the top of the note "pulmonary/CCM." In the body of the note, it does not indicate that he saw the patient in CCU, nor does it states a time. I am thinking again, he is assuming because he wrote pulmonary/CCM that this is suffice.


I'm sorry one more thing,
Someone told me today, that the start and stop time shoud be documented. Is this true? I thought if the total time is documented, this would be sufficient. I know this is true for discharge patients, but I don't recall seeing this in the guidelines for CC.


I don't code crital care that often, in fact it's been awhile, so I had to refresh by reading the guidelines, so please let me know if there is anything thing else I should know. Thanks!


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## FTessaBartels (Jun 2, 2009)

*Guidelines for critical care*

Read the guidelines in CPT for critical care carefully.

The patient must be critically ill (may or may not be in the ICU).
*-AND-*
The care provided must be critical care.
*-AND-*
The care must be face-to-face (includes unit/floor time in an inpatient setting) for at least 30 minutes. (Time MUST be documented in the note.)

Writing on the encounter form or patient list is not official documentation. 
Simply stating that the patient is in the ICU is not sufficicient documentation.
(and, conversely, you CAN provide critical care to a patient who is NOT currently in the ICU ... happens in the ED all the time.)

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## Trendale (Jun 3, 2009)

*reply*

Hello,
Thanks for that information. So does the physician needs to dictate the note every time, along with the total time he spent ( does it matter how he specifies the time, ex. start/ stop or total time)? His hand written note, even though it has pulm/CCm on it along with the time, should not be coded as a CC, it should be coded as a F/U? I just didn't see this in the CPT regarding handwritten or dictated. I agree with your response, I am just asking just in case I will have to provide supporting documentation. This can be a potential issue with this particular physician because he sees over 500 pts f/u visits, and more than half has pulm/CCM on the note, and I believe he assumes he can get a CC code out of this, so I just want to make sure I am on top of it with supporting documentation, do you know of a link I can go to as well? 

The following is what he does on his F/U visits, thinking it should be a CC code:

Say the patient meets the criteria for CC coding, the physician documents the necessary statement in the note, subsequently, he sees the patient over the next several days in CCU or another area, the patien's conditon is still life threatening, medical D making is High, but the physcian does not state it, and he is documenting as handwritten on a progress note, but does not state any of what I just mentioned, he just says the pateint has improved, better or worse, he does an exam and medical decision making. Should this be a CC code or subsequent code?

Thanks!


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## Lashel (Jun 3, 2009)

I am in agreement with the previous reply. Do not make the mistake of assuming that a patient in ICU requires critical care.  I would absolutely ask your physician to document time in and time out. I personally think that is optimal for documentation purposes. However, there are other acceptable ways for documenting time. 

Time spent reviewing tests, discussing, and documenting can be counted in that time. I think that is an area that loses some revenue for offices. Also, if the patient is not able to participate in the discussions, the time spent talking to the family about history, condition, prognosis, etc can be counted if this time directly correlates to the care of the patient.


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## Lashel (Jun 3, 2009)

Critical care is defined by CPT as "high probability of imminent or life threatening deterioration in the patient's condition." A patient can be very ill, require lots of care, be in ICU, and still not be in imminent/immediate danger of death or organ failure. Critical care basically means that intervention is required to keep this patient alive right now. Later in the day their condition may still be life threatening, but not in immediate danger of deriorating further. I hope that helps


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## tfischer (Jun 3, 2009)

I agree with the previous replies as well. However, I just went to a conference about a month ago and was told that the start and stop time is not needed. Just the total time spent with the patient excluding any procedures.

_Critical Care is defined as a physician's direct delivery of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ system(s) such that there is a high probability of imminent or life threatening deterioration in the patient's condition._ I was also told at this conference, if there is an organ failure involved, it must be used as the primary diagnosis.


If the physician does not document time, he must make an addendum to the note, or otherwise it is automatically coded as a subsequent stay.


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## Lashel (Jun 3, 2009)

The best documentation of time is start/stop time. Especially because physicians are often in and out. They may be called in at 8:00 for respiratory failure, again at 1:00, and again at 2:00. So by documenting the start/stop time you make for a much stronger record. However, it is permissable to document the time spent, but harder to defend in an audit situation.


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## FTessaBartels (Jun 3, 2009)

*Handwritten notes okay*

Letisha - 
A handwritten note is perfectly fine as long as it meets the documentation standards.

Total time spent must equal *30 minutes *or more ... and can be the result of multiple shorter visits throughout the day. ALSO, as previously mentioned the time spent on the floor/unit (directly related to THIS patient's care) is also counted in the total time.

The patient does NOT have to be in imminent danger of death .. but there must be a "*high probability*" of imminent danger of death/deterioration. A patient may even be improving, but still at high risk.  That's why it is so important for the documentation to include some statement as to WHY the patient is deemed critically ill, and WHAT the critical care is that is provided. 

Even when a patient is critically ill, not every physician who sees that patient will necessarily be providing critical care (e.g. comatose patient on a ventilator who is seen by a dermatologist to evaluate rash) 

Based only on what you've described - and without having *actually* seen any of your physician's notes - it does *not *sound as if his/her documentation is up to the standard for billing critical care in most cases.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## Karolina (Jun 4, 2009)

In addition to the prior statements regarding time and documentation keep in mind that the physician attending to the critical care patient must devote the time spent for this patient (face-to-face or floor/unit) 100% to that patient. S/he must be immediately available to that particular patient and cannot see other patients during that time.


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