Wiki Critical Care coding policy

[chickelala]

Help - I have been charged with writing the critical care coding policy for our facility. Would anyone be willing to share your policy with me as an example?

Thanks!

 

[Pam Warren]

Coding Guidance: Critical Care and Documentation of Time​

Per CMS: ?Critical care services must be medically necessary and reasonable. Critical care services encompass both treatment of ?vital organ failure? and ?prevention of further life threatening deterioration of the patient?s condition.? Therefore, although critical care may be delivered in a moment of crisis or upon being called to the patient?s bedside emergently, this is not a requirement for providing critical care service. The treatment and management of the patient?s condition, while not necessarily emergent, shall be required, based on the threat of imminent deterioration (i.e., the patient shall be critically ill or injured at the time of the physician?s visit).

Critical care is a time- based service, and for each date and encounter entry, the physician's
progress note(s) shall document the total time that critical care services were provided. More than one physician can provide critical care at another time and be paid if the service meets critical care, is medically necessary, and is not duplicative care.?

GUIDANCE:

The documentation of critical care is essential for determining medical necessity of the critical care charges. Documentation of imminent deterioration, organ failure, severe trauma, or life-threatening condition is essential. Coders are encouraged to query the provider to clarify the diagnosis, management or patient status in order to validate critical care billing.

Because critical care services are time-based, the provider must always document the amount of time spent in providing critical care. The preferred documentation would indicate, ?Two hours and fifteen minutes were spent with this patient performing critical care services?, as long as the note could substantiate that the physician work provided, was indeed to care for the critically ill patient. If time was documented without including the words ?critical care?, the service can be billed as long as the documentation supports the care of a critically ill patient.


STANDARDS:

? Documentation must show a problem/status/treatment that supports critical care. Coders may query the provider for verification or clarification.

? Critical Care Time must be documented in the patient?s chart in order to be billed.

? Statement of time spent does not need to include the words ?Critical Care?, however the documentation of the care given must support care of a critically ill patient.

? Critical Care time can be noted either in the critical care note (preferred), or referenced in the physician orders.

? If the critical care time is noted in the orders, a physician query or addendum is appropriate for clarification, if necessary.

RESPONSIBILITIES: Physician Services Coding, all WDH and WDPC employed physicians

REFERENCES:
Medicare Claims Processing Manual
Chapter 12 - Physicians/Nonphysician Practitioners http://www.google.com/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&ved=0CCwQFjAA&url=http%3A%2F%2Fwww.cms.gov%2FRegulations-and-Guidance%2FGuidance%2FManuals%2Fdownloads%2Fclm104c12.pdf&ei=MLF8VMvLHoXLsAT40oCQAw&usg=AFQjCNFXTG2bUIPbG62MOJj-b886Dj-bxw&bvm=bv.80642063,d.cGE


An additional policy we have that pertains to this one is that in the instance of two E&M visits (including critical care) per day, the visits are coded together by documentation and by service, and billed under the provider who saw the patient first on that calendar day.