# critical care documentation



## ggparker14 (Jul 14, 2013)

Can anyone please verify that I am correct on critical care documentation with resident involvement?

If the resident documents critical care time of 30 minutes excluding time spent on other procedures, does the teaching physician have to also state the exact amount of critical care time involved or is it acceptable for the teaching physician to state he was present and participated in the care of the patient and he agrees with the resident's findings?

I guess I am curious to know if the teaching physician must document the "critical care time of 30 minutes" and if not, it is not acceptable documentation to bill critical care in this case?

Thanks for any help.


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## jimbo1231 (Jul 15, 2013)

*30 Mintes*

Since per CMS the Teaching Physician must establish 30 minutes in the presence of the patient and managing the resident, I'm not sure why they would be hesitant to also document time. I've found that when attendings get skittish about documenting their actual participation with a patient under a resident's care, it could mean they didn't. But I didn't see anything that states speifically that the term "30 minutes " must be used by the attending. But i certainly think that is a best and safe from audit practice.

Jim


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## FTessaBartels (Aug 5, 2013)

*Attending documents time*

In our practice, the resident/fellow may document the note, but the attestation - AND THE TIME SPENT IN DIRECT CRITICAL CARE is documented only by the attending.

This way there is no question that the documented time is the time that the attending physician (i.e. the one we bill for) spent with the patient.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## ramirez505 (Aug 10, 2013)

Time spent alone by the resident (i.e., performing critical care activities in the absence of the teaching physician) cannot be counted toward critical care time. Only time spent performing critical care activities by the resident and the teaching physician together or the teaching physician alone can be counted toward critical care time. 

The teaching physician may tie into the resident's documentation and may refer to the resident's documentation for specific patient history, physical findings and medical assessment. However, the teaching physician must still document a statement of the total time the teaching physician personally spent providing critical care, that the patient was critically ill when the teaching physician saw the patient, what made the patient critically ill, and the nature of the treatment and management provided by the teaching physician. 

The following vignette is provided by CMS as an example of acceptable documentation: 

"Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident's documentation and I agree with the resident's assessment and plan of care."

See CMS Transmittal 1548 for further details.


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