Wiki Critical care - most encounters

[MnTwins29]

I will be doing an audit of our hospitalists and I will be using an E/M audit tool for most encounters. However, I wanted to see if anyone has a tool or form they have used before for critical care, since those codes are used in some of the encounters. Does anyone have a checklist of what to look for to ensure that it is appropriate? Or if you have audited critical care before, what do you use or look for?

TYIA.

 

[FTessaBartels]

Three components to critical care

1) the patient must be critically ill
2) the care provided must be critical care
3) time (at least 30 minutes) must be documented for DIRECT PATIENT CRITICAL CARE.

We train our physicians to state WHY the patient is critical (the coders are not clinicians and we cannot interpret lab values to determine that the patient is critically ill). Then to outline the kind of critical care they provided and the plan for continued treatment (ventilatory managment, medication management to support major organ systems, intensive monitoring, etc). Then to document the amount of DIRECT TIME spent in providing critical care to this patient.

Hope that helps.

F Tessa Bartels, CPC, CEMC