Ensure ED Providers Document All Their Critical Care Time

The appropriate critical care codes are determined by the physician’s total time.

On-target provider documentation is critical to reimbursement – more specifically for time-based codes for services such as critical care. Auditors are increasingly cynical of generic documentation that’s not specific to the patient or encounter. Using 30-74 minutes language that’s included in some templates and EMRs seem to fit the CPT^® code descriptors. However, don’t rely solely on attestation.

Make sure that your Emergency Department (ED) providers are well-equipped with what documentation is needed to substantiate the time reported.

Where to get time-based documentation guidelines? 

·         CPT Book: CPT^® mentions that “Time spent with the individual patient should be recorded in the patient’s record”.

·         CMS Manual: “The physician’s progress note(s) shall document the total time that critical care services were provided”. CMS transmittals also tell us that the use of “shall” denotes a mandatory requirement.

Physicians and coders watch out: ““The physician’s progress note(s) in the medical record should demonstrate that time involved in the performance of separately billable procedures was not counted toward critical care time.”

Ensure the highest standard of documentation

CPT^® code 99291 doesn’t use numerical documentation requirements for history, physical exam and medical decision making for code selection the way E/M codes do. As an alternative, the proper critical codes are determined by the physician’s total attention time.

Warning: But that does not mean that those E/M elements can be omitted from a critical care chart. These elements are required to show that the patient has a critical illness or injury that deeply impairs one or more vital organ systems such that there’s a high likelihood of looming or life threatening weakening in the patient’s condition.

Heed this: For on-target critical care reporting, document should point to the total amount of time the physician devoted their full attention to the patient providing critical care services. It would be ideal to see a short explanation of the critical nature of the patient, the critical interventions and other activities that added up to XX minutes to make a bullet proof chart.

According to many policy resources, the physician should document their total attention time, and ED physicians should document to that standard. The time range indicated in the code descriptor is for the coder to use to choose the appropriate CPT^® code based on the total time documented by the physician.

Your documentation should comply with coding guidelines and CMS policy to ensure that there’s no room for the auditor to argue that the ED chart doesn’t correctly reflect the service that was provided and/or the code that was reported.  If you need more help to ensure this and increase your compliance confidence, use Inpatient Facility Coding & Compliance Alert - a monthly newsletter that boosts your bottom-line and ensures compliance by focusing on topics specifics to hospitals – from time-based coding guidance, documentation advice and ICD-10-PCS implementation tips to DRG selection, modifier usage advice, and more.