Inpatient Facility Coding & Compliance Alert

Question: Would a template listing a range of time spent rather than a specific time statement providing critical care time be acceptable for documenting the duration of service?

North Carolina Subscriber 

Answer: Although the templated time range concept may sound attractive, proceed with caution. The critical care section of CPT® does include a chart of time ranges as a guide for which code or codes should be used to report the duration of critical care provided.

Example: If the total duration of critical care was 75-104 minutes (1 hr. 15 min. - 1 hr. 44 min.), the appropriately assigned E/M codes would be 99291 and one unit of 99292. If you were to consider a templated set of ranges, it would be best to mirror those in the CPT® chart. Any other time ranges would create more problems than they would solve. However, some payers, including Medicare, want a specific time statement along the lines of, “I spent 57 minutes providing critical care services net of any other separately reportable procedures.”

Since critical care services are often the focus of audit scrutiny, in this case, you should err on the side of clearly patient-specific documentation. If the templated time options looked identical in the majority of critical care charts (and the vast majority would), that would make auditors suspicious about the accuracy of that statement in any individual chart. If your EHR currently has a templated range, consider adding a specific time in free text.  Also, check with any associated billing policies and procedures for critical care services.