I have been told by a couple of CMS carriers that they would prefer to see the time in and time out as you mentioned but it is still ok to just have total time spent documented.
I want to add a question of my own to this.
I have a handwritten note (very poorly written, shocking I know) that is for critical care. The provider that first responded to the code documents the time they started, and they did the intubation. They do not document total time or out time, have no clue what they billed since they aren't one of my providers. My provider arives on the scene shortly thereafter. No start time but does document "critical care time 135 minutes". This patient did go into cardiac arrest. My provider documents "CPR<2minutes, Epi x 2, cardioversion" he then lists a couple of elements of exam which were when the patient stabilized, I think. On the side of the note he documents "Intubated, Art Line, Vent Management, Bronchoscopy, CPR, Cardioversion". There are no other procedure notes, nursing notes support he did the bronchoscopy and the art line.
When I originally looked at this I said we can't bill critical because I have no idea how long it took to do the procedures that need carved out so I have no true time. It has made its way back to my desk for a second look so I am asking for other opinions. I don't doubt he did critical care, I just don't think I can bill for it based on the note. The patient does not have Medicare, it would have been included with the surgical global period if they had.
Thanks
Laura, CPC, CPMA, CEMC