Pediatric Coding Alert

Question: I've heard about the importance of documenting critical care time. As a pediatrician, does that mean every time I enter and leave the room, I need to look at my watch? Florida Subscriber

Answer: You don't have to be a watch watcher. Instead, check the time when you initiate critical care services, for instance at "0900." Then, record the time at the end of the session, such as "0935." Subtract any time for procedures that you can separately report, such as endotracheal intubation. If you stabilize a patient who then crashes again, record another start and stop time. Alternative: A nurse's documentation can also suffice. If during critical care a nurse records all actions and times, you can determine the critical care time from her notes. You should then summarize the total time you spent with the patient in the chart note, such as 35 minutes (99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), and note the services you provided during that time. In the event of an audit, recording your duties will support your claim of providing critical care services (99291 and possibly +99292, ... each additional 30 minutes [list separately in addition to code for primary service]). You should also document that the patient is critically ill, which requires that the patient has at least one organ system that is failing and that the patient's life is in jeopardy without intervention. The critical care services must meet the critical care codes' time requirements.