Neurosurgery Coding Alert

Question: The patient's chart includes the following statement: "Critical care time spent on this patient with probable acute meningeal process such as bleed and/or meningitis is 75 minutes. Half this time is spent on review of data present and previous and medical decision making." Is this sufficient documentation to justify coding the note as critical care?

Ohio Subscriber

Answer: Critical care is a time-based service, and for each date and encounter entry, the physician's progress note(s) should include the total time that critical care services were provided. The CPT section guidelines for critical care state, "Critical care of less than 30 minutes total duration on a given date should be reported with the appropriate E/M code." Your physician spent enough time to report critical care, but make sure you have complete documentation of the specific care he provided. If so, you'll report 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]) because his service went beyond 74 minutes.

Remember: The physician doesn't have to remain by the patient's bedside for the entire block of time documented. As long as he is devoting his full attention to the management of the critically ill patient, you can count the minutes toward critical care codes.