Coding and Documentation Is Crucial in Supporting Critical Care Services Deborah Grider, CPC, CPC-P, CPC-I, COC, CPMA, CEMC, CCS-P, CDIP Documentation should paint a picture of the patient’s condition. Provided that all requirements for critical care services are met, the teaching physician documentation may tie into the resident's documentation. Teaching Physician & Critical Care Teaching physician care must meet all criteria listed above along with the following: 1. The physician must document the total time spent providing critical care in the patient’s record. When doing so, the provider must be careful not to count critical care time for any services not directly related to care of the critical patient. The products and services of HCPro are neither sponsored nor endorsed by the ANCC. Subscribe to JustCoding News: Outpatient! Coders report critical care codes based on time, medical necessity, and interventions provided. Collaboration, physician supervision and billing requirements must also be met. Examples include but are not limited to: the patient is worsening, unchanged, improved, remains critical, poor prognosis, stable but remains critical, stable but remains unchanged, and any other clarity which can be provided at the time. I recommend structuring the trauma flow sheet to capture all data required by your center’s critical care policy. Silvermoon Whitewater Taggart, MBA, CPC, AAPC Fellow is Practice Administrator at Pulmonary and Internal Medicine Associates, Inc., a nine provider practice in Stuart, Fla. on Critical Care Documentation Essentials, UnitedHealthcare Makes Fourth-Quarter Policy Changes, The Weirdest Thing About Critical Care Coding, Count Only Included Services when Reporting Time. Monitoring and Documentation Requirements Critical Care June 2020 For more information, contact policy@ahs.ca Restraint Type Assess & Document Assessment includes the determination of the least restrictive restraint possible or discontinuation of restraint. Since critical care is a time-based code, the physician’s progress note must contain documentation of the total time involved providing critical care services. CPT and the Centers for Medicare & Medicaid Services (CMS) define “critical illness or injury” as a condition that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition (e.g. Examples include but are not limited to: the patient is worsening, unchanged, improved, remains critical, poor prognosis, stable but remains critical, stable but remains unchanged, and any other clarity which can be provided at the time. Progress notes must document the total time the critical care services were provided for each date and encounter entry. Emergency Departments (EDs) see a wide range of illnesses and injuries, from minor to major, which may require critical care. The physician must document time spent in order to bill for critical care. Medical necessity drives every patient encounter. emergency room or ICU). Additionally, a patient may be stable and still meet the requirements for critical care. Or is it acceptable for that last couple minutes(1-5ish) to simply say don’t worry about it, and bill only 99291 x1, 99292 x6? The physician medical record documentation must provide substantive information: The patient’s condition must meet the definition of a critical illness or injury described above. A critical illness or injury is further defined as an impairment of one or more vital organ systems, with imminent or threatening deterioration in the patient’s condition. Decisions about the use of critical care resources should only be made by, or with the support of, healthcare professionals with expert knowledge and skills in critical care. ICD-10 Documentation Tips for Pulmonary ICD-10 Documentation Tips for Critical Care Nontraumatic Subdural Hemorrhage 1) Document type: -Acute -Subacute or -Chronic Traumatic Brain Hemorrhage 1) Document site, such as -Left or right cerebrum, cerebellum, brainstem, epidural, subdural, subarachnoid 2) Document if with loss of Documentation Requirements. If less than 30 minutes are provided, coders should report the appropriate E/M codes. As stated above, the physician must attest that critical care was provided and the amount of time he or she provided such care. I completely understand your confusion… Allow me to clarify…. Each physician must accurately report the service(s) he/she provided to the patient in accordance with any applicable global surgery rules or concurrent care rules. For ED patients, coders would report … This follow-up to our popular Injections and Infusions audio conference delves into more coding questions and responds to... *MAGNET™, MAGNET RECOGNITION PROGRAM®, and ANCC MAGNET RECOGNITION® are trademarks of the American Nurses Credentialing Center (ANCC). In the meantime, start XYZ to minimize further complications…” Here are some common problem areas coders run into when reporting critical care services. As an alternative to documenting total critical care time, the provider may document start and stop times. Why am I changing the plan of care? The plan should always include the patient’s status. Coders should look for a statement similar to this: I personally provided 30 minutes of critical care to this patient. The provision of critical care services must be within the scope of practice and licensure requirements for the State in which the qualified NPP practices and provides the service(s). Knowing the definition of “critical care” is a key factor that directly impacts accurate and timely reimbursement for physicians and their practices. These services include but are not limited to: Defining time spent providing critical care. If less than 30 minutes are provided, coders should report the appropriate E/M codes. For example, “The patient is stable but remains critical at this time. 4.4 . For instance, if the provider signs a lab order for a different patient during the start and stop time of providing critical care, the time spent reviewing and signing the lab order cannot count toward the critical care time for the critically ill/injured patient, even if the individual is on the floor. Report the time you spent evaluating, managing, and providing the patient’s care including reviewing lab tests, discussing with consultants and family, and documentation. Critical care codes are reimbursed at a substantially higher rate than those for acute care, so you need to make sure you reap your well-deserved reimbursement for the critical care services you provide. This should be detailed enough to support that critical care visit and continued critical care visits, as necessary. In order to charge for critical care services, the physician must document at least 30 minutes of critical care. Critical care codes are time-based. There must be at least 30 minutes of Critical Care time. Critical Care services (99291-99292) are time-based, and improper documentation of time is a frequent reason that payers deny payment for these services. Want to receive articles like this one in your inbox? The Importance of Time Documentation. Documentation is for the correct beneficiary. In Part 2 of this series, Provider Time and Documentation, we will summarize the numerous documentation and coding rules and requirements related to provider time. The plan should always include the patient’s status. Critical illness acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition. Escalate: When you encounter a record that you believe should be charged as critical care, but find no physician attestation, contact your manager for guidance. Critical care staff should support healthcare professionals who do not routinely work in critical care but need to do so (see guidance from the Faculty of Intensive Care Medicine). Critical care services are time-based, which makes provider documentation of time an essential coding element. The physician must document the total time spent providing critical care in the patient’s record. The documentation must support both the physician and resident were present for the critical care time billed 3. But would your critical care documentation hold up to the scrutiny of an audit? Send a concise statement to the physician explaining what is needed and requesting the physician add the needed documentation to the record. I reviewed lab work, changed the patient’s medication, and coordinated protocol in the event of tachycardia or desaturation.” They may or may not be aware of documentation requirements. Medical record documentation must support the medical necessity of critical care services provided by each physician (or qualified NPP). When multiple physicians are involved, the documentation must support the medical necessity of the critical care services rendered … Q/A: Using modifier -59 with EKGs and cardiac catheterization, Q&A: Proper sequencing of heart failure with hypertensive heart/kidney disease, Plan of Care Supports Documentation of Homebound Status, One or more vital organs or organ systems are impaired, The patient’s condition has a high probability of immediate deterioration, If critical services are not immediately rendered, the patient faces a high probability of death, Assess, manipulate, and/or support vital organ function, Treat single or multiple vital organ failure, Prevent the further deterioration of the patient’s critical condition, Circulatory system (such as heart attack), Physician must be in attendance at the bedside or immediately available in the unit or the immediate area of the patient during the time charged, Actual time spent providing care can be accumulated over a 24-hour period; however, only the time spent providing actual care may be charged, Physician must document total time spent providing critical care, Coders may not surmise that critical care was provided nor may they calculate actual time spent providing critical care based on diagnosis, interventions, or times written on physician notes, Codes are based on time: report CPT code 99291 for the first 30-74 minutes, Report CPT code 99292 for each additional 30 minutes, Family meetings to ascertain medical care for patients unable to make their own decisions. For Critical Care documentation: The plan should always include the patient’s status. Checklist: Critical care services documentation . Elements of Critical Care Time Critical illness or injury = illness or injury that impairs one or more "one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.” For Critical Care documentation: So I am definitely having trouble understanding critical care, the above example , For example, “The patient is stable but remains critical at this time. Critical care treatment falls under Evaluation and Management (E&M) services billed with codes 99291 and 99292. Document an exact time rather than a time frame. Nursing documentation is essential for good clinical communication. Critical care CANNOT be submitted as a split/shared visit. Critical care notes do not have specific bulleted items; therefore, it is imperative the documentation contain enough information to distinguish critical care from other E/M services. Some facilities allow coders to provide this information to physicians. If less than 30 minutes are provided, coders should report the appropriate E/M codes. Code 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes reports the first 30-74 minutes of care; while 99292 …each additional 30 minutes (List separately in addition to code for primary service) reports additional blocks of time in 30-minute increments beyond the first 74 minutes. If I did not modify the plan of care, what are the potential outcomes? I guess I’m asking how exacting and concrete vs how fluid you need to be for this sort of instance. Critical Care documentation should always include the following: The organ system (s) at risk Which diagnostic and/or therapeutic interventions were performed, including rationale Critical findings of laboratory tests, imaging, ECG, etc., and their significance At least 30 minutes of Critical Care Hospitals that provide less than 30 minutes of critical care when trauma activation occurs under revenue code 68x, may report a charge under 68x, but they may not report HCPCS code G0390 As an example of proper documentation of critical care services, the physician might specify, “I spent 180 minutes of critical care time excluding the procedure time. Critical care patients are occasionally “critical” day after day. Additionally, medical record documentation for each physician is more clearly written in Section I and the requirement for CPT code 99291 is underlined for emphasis. However, if the documentation of a critical care case does not meet CMS standards, or if the total critical care time is less than 30 minutes, the chart will be billed according to E/M codes. She has 16 years experience working in the healthcare industry. Have your physician ask himself or herself the following, and document the answers: What happened since I left the patient last? For ED patients, coders would report E/M codes for emergency services. A combination of the resident and physician’s documentation must support that critical care was Time cannot be the same for each critically ill patient. Critical care codes are time-based. Because of the time requirement for coding critical care, these cases cannot be coded using critical care codes. Therefore, documentation should focus on what transpired from the last time the patient was seen until the present; listing all circumstances that emerged that effect the current plan of care. Some departments provided templates with a check box for such a statement and a blank where the physician can note the actual critical care time. of critical care (CPT code 99291), the hospital may also bill one unit of HCPCS code G0390. The plan is to perform a thoracentesis and send the results for further testing. These are fine as long as the physician actually checks the box and fills in the time. Critical care notes do not have specific bulleted items; therefore, it is imperative the documentation contain enough information to distinguish critical care from other E/M services. For example, should a patient be seen for 4 hours and 15 minutes (255 minutes). Critical care is defined as the time spent engaged in work directly related to the patient’s … Documentation is for the correct date of service. A physician assistant shall meet the general physician supervision requirements. Physician education: Physicians are extremely busy. 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