Wiki Critical Care

[Gemini18]

I'm auditing a record that's originally billed as a critical care 99291. The time in not noted in the actual notes but on the physician's billing sheet only. Time stated is: Crit. Care Time 35 min.

Is this appropriate?

 

[FTessaBartels]

No

Not documented, not done.

The billing sheet is NOT part of the medical record. The documentation of the service MUST include the time spent providing direct critical care to the patient (and must be 30 minutes or more).

Given that the physician included the time on the billing sheet, I would accept an addendum to the original dictation specifying the time.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[Gemini18]

Not documented, not done.

The billing sheet is NOT part of the medical record. The documentation of the service MUST include the time spent providing direct critical care to the patient (and must be 30 minutes or more).

Given that the physician included the time on the billing sheet, I would accept an addendum to the original dictation specifying the time.

Hope that helps.

F Tessa Bartels, CPC, CEMC

Thanks Tessa

 

[Belinda Frisch]

Narrative

I agree with that, but have another question to pose: is anyone else putting total critical care time on the claim form as a narrative to support their coding? I was recently in a McVey teleconference that recommended it. Does anyone else see requests for medical records frequently for critical care?