JWash618
Networker
I have a doctor wanting to bill a critical care code on the same day as surgery. On his cover page he wrote the care DX as respiratory failure, the epic note goes on to explain (this is post surgical) the history exam and assesment, none of which say anything about respiratory failure. This was all done by a resident. At the bottom of the note the doc has an attestation statement saying he was present and agrees with the resident and "This patient was "admitted with unstable or critical vital signs in need of continuous hemodynamic and/or respiratory support. I directly participated in this patients care for 35 minutes."
Is that enough to qualify for the critical care code or does all that info about being critically unstable etc need to be reflected in the body of the epic record?
Is that enough to qualify for the critical care code or does all that info about being critically unstable etc need to be reflected in the body of the epic record?