# E/M or documentation requirements for Critical Care?



## Love Coding! (Jan 20, 2010)

Hello,

Other than total time spent, are there any E/M documentation requirements or documentation requirements (HX, Exam, MDM)?  Also has anyone else heard about the physician documenting the start and stop times for Critical Care?  I have been told that it helps with audits, in regards to if the patient crashes later in the day.

Thank you!

GeminiCoder74


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## FTessaBartels (Jan 20, 2010)

*Critical Patient / Critical Care*

The patient must be critically ill.  The care provided must be critical care. The direct face-to-face time (includes floor/unit time if patient is hospitalized) must be documented and must be at least 30 minutes. 

Most of our intensivists dictate a two-page single spaced note that is very detailed and includes a statement as to the critical nature of the patient's condition. 

But, a physician might be able to document critical care in a couple of sentences.  As long as the documentation is clear as to the patient's condition and that at least 30 minutes of direct critical care was provdied.

Hope that helps. 

F Tessa Bartels, CPC, CEMC


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## LTibbetts (Jan 20, 2010)

Actually, you *have* to document the time spent in order to charge any critical care codes. Read that section in your CPT book very carefully, I know there is a lot there but it is very informative for the use of these codes. It could cost you a lot down the road if the providers there haven't been doing that up to now. Critical care is a *time-based *code set. As for the documentation requirements, check both sets of your E&M guidelines (95 or 97) to see what is needed to bill certain codes.


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## LLovett (Jan 20, 2010)

I have been told by a couple of CMS carriers that they would prefer to see the time in and time out as you mentioned but it is still ok to just have total time spent documented.

I want to add a question of my own to this.

I have a handwritten note (very poorly written, shocking I know) that is for critical care. The provider that first responded to the code documents the time they started, and they did the intubation. They do not document total time or out time, have no clue what they billed since they aren't one of my providers. My provider arives on the scene shortly thereafter. No start time but does document "critical care time 135 minutes". This patient did go into cardiac arrest. My provider documents "CPR<2minutes, Epi x 2, cardioversion" he then lists a couple of elements of exam which were when the patient stabilized, I think. On the side of the note he documents "Intubated, Art Line, Vent Management, Bronchoscopy, CPR, Cardioversion". There are no other procedure notes, nursing notes support he did the bronchoscopy and the art line. 

When I originally looked at this I said we can't bill critical because I have no idea how long it took to do the procedures that need carved out so I have no true time. It has made its way back to my desk for a second look so I am asking for other opinions. I don't doubt he did critical care, I just don't think I can bill for it based on the note. The patient does not have Medicare, it would have been included with the surgical global period if they had.

Thanks

Laura, CPC, CPMA, CEMC


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## Love Coding! (Jan 20, 2010)

FTessaBartels said:


> The patient must be critically ill.  The care provided must be critical care. The direct face-to-face time (includes floor/unit time if patient is hospitalized) must be documented and must be at least 30 minutes.
> 
> Most of our intensivists dictate a two-page single spaced note that is very detailed and includes a statement as to the critical nature of the patient's condition.
> 
> ...



Thank you Tessa that answered ny question and thank you to all that responded to my question -

GeminiCoder74


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## Cyndi113 (Jan 20, 2010)

Laura, 

It's very interesting that you pose this question. I also have a similar note and keep putting it to the bottom of my pile. I have been procrastinating because I know my doc will argue with me if I tell him I can't bill it. 

I'll be checking back for answers to your question.


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## FTessaBartels (Jan 20, 2010)

*Time is EXCLUSIVE of procedures*

Laura,
If I understand your scenario correctly, you have only a brief handwritten note with notation of 135 minutes critical care time.  But the note mentions a number of procedures (bronchoscopy, intubation, CPR, Art line). 

If this were my doctor I would tell him that he has to separately document each procedure done (so that I can bill for them), and he has to then stipulate how much time EXCLUSIVE of PROCEDURES was spent in critical care. 

But I seem to recall that you have some physicians who are deaf to your advice. Maybe the dollars will help sway them.

By my count (assuming Medicare payment) if you billed the CPR, Art line, Intubation and bronchoscopy plus 99291 (let's assume he has 1 hour or less of the 135 minutes left after all the procedures) Medicare would pay $670 (give or take ... for Wisconsin)

If you just coded for the 135 minutes of critical care  -  99291 + (99292 x 3) - Medicare would pay $510 (give or take ... for Wisconsin) - or only 75% of what you would get if you had documentation to code the procedures separately.

Hope that helps. 

F Tessa Bartels, CPC, CEMC


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## tkcole1 (Jan 31, 2014)

I realize this thread is a few years old but have been looking for some clarification of documentation requirements of critical care time so thought I'd post my question here hoping maybe someone would still respond.
Does documentation of critical care require the time statement to be worded to state that the provider spent ">45 minutes providing critical care" or is this type of time statement also acceptable if provider documents a statment like this? ">45 minutes spent in care of this critically ill patient"
Does stating the patient is "critically ill" meet the documentation requirement or does the provider have to specifically state that they were "providing critical care"?
Any information would be appreciated
tkcole1


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