Wiki The words "critical care"

[Love Coding!]

Hello I hope that someone can guide me as to where I can find an answer for my question below.

Does the physician have to document the words "critical care" along with the time spent with the patient in order to bill for critical care services?

I guess what I am getting at is that if the words "critical care" were absent in the documentation, but the physician documents the time spent with the patient can he still bill for critical care?

Thank you,

 

[hewitt]

There is a parenthetical note in the CPT book that explains what qualifies as Critical Care Services. Might be better to review that and compare it to the note detail you have. Time must be documented when using timed CPTs.

 

[aaron.lucas]

I agree with hewitt, you don't necessarily need those specific words in the notes, as long as the documentation supports it based on the guidelines, and you have the time documented. On the other side of that token however, simply saying "critical care" doesn't make it so, again your notes have to support it.

 

[OCD_coder]

If the documentation simple stated: "I spent 35 minutes with the patient."

How would a coder decipher/abstract this as critical care and not face to face time in counseling the patient?

The status of the patient is needed so that the correct code family can be determined by the coder since critical care can be provided in any location. I could not code or defend/appeal critical care without the specific verbiage "critical care time with the patient" missing - Best Practice.

Reference:
http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/MM5993.pdf

 

[Love Coding!]

If the documentation simple stated: "I spent 35 minutes with the patient."

How would a coder decipher/abstract this as critical care and not face to face time in counseling the patient?

The status of the patient is needed so that the correct code family can be determined by the coder since critical care can be provided in any location. I could not code or defend/appeal critical care without the specific verbiage "critical care time with the patient" missing - Best Practice.

Reference:
http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/MM5993.pdf

Thank you everybody for responding! Thank you Michelle, that's exactly what I thought also. Also thank you for the link...