Wiki Critical care time

[MissyKoehler]

If you have a pt that clearly meets critical care, but the dr doesn't document time can you lead your physician's to review the record and possibly make an addendum to the record to add critical care time? For some reason I am thinking this is a no no but I can't find anything on it in writing. Can anyone give me any guidance and if you know where I can find supporting documentation I would greatly appreciated.

 

[FTessaBartels]

A gentle inquiry

I've been known to ask a physician ..." Patient X sounds pretty sick to me. Did you spend at least 30 minutes with them providing critical care? If so, please document this so we can appropriately code."

Sometimes the physician hasn't spent 30 minutes with the patient. Sometimes the physician just forgets about the critical care code (especially if they don't use it often), and a gentle reminder is all they need ... if the physician adds the time spent in critical care, then we'll code it as such.

Hope that helps.

F Tessa Bartels, CPC, CEMC