ED Coding and Reimbursement Alert

Question: We have a critical care claim in which the physician's documentation meets all critical care documentation guidelines except the total critical care time provided. On the template, he circled "critical care" but didn't note the actual time spent. Should I send this chart back to the provider for completion, or should I use it as an educational tool for future use and just report a level-five service? My concern is that the payer may view sending the chart back for an addition of time as adding documentation for reimbursement purposes only.


Illinois Subscriber

Answer: You should certainly send this chart back to the physician for clarification. Many compliance plans allow critical care clarification in this scenario, so you shouldn't get into trouble with a payer as long as you have the documentation you need.

The care of a critically ill patient is very demanding, action-oriented, and occasionally chaotic. If every aspect of the chart isn't absolutely perfect during the course of stabilizing a critically ill patient, this is reasonable because the doctor's attention is focused on the urgency of the patient's treatment.

You should differentiate between adding history of present illness elements (in effect, changing the history) and accurately attesting to what the physician performed.

With addition of a critical care attestation, you are stating retrospectively what the physician did - not beefing up the history, physical examination, or medical decision-making elements. Think of this additional information as a clarification that allows you to code the chart accurately, especially when reporting 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (... each additional 30 minutes [list separately in addition to code for primary service]).