Forum - Questions & Answers
Critical Care documentation
Provider is charging critical care CPT® code 99291. Although time is documented, I'm not sure that this stand alone note clearly supports critical care. Do you agree or disagree? All feedback/guidance is appreciated!
Pt seen in ICU
Sedated (given Ativan in ECC)
Extemely weak
NAD but appears ill
VS tachy @ 110s
BP sl high
Lungs clear
Abd soft NT
Neuro Non focal
Labs reviewed
IV k, PO4, Mg ordered
Serum Acetone, UA ordered
Ethylene glycol, methanol level pos
Discussed with dtrs at length Re:
Condition, Dx, prognosis, POC.
CCT spent 30 min.
re: Critical Care documentation
I don't think this supports critical care because it does not state the patient critical problem like heart failure, respiratory arrest, shock, cardiac arrest etc...anything that shows patient is in danger of losing life. It gives time spent but all 30 min was not with patient
re: Critical Care documentation
I don't believe this documentation supports critical care. Patients in ICU may not always meet critical care coding criteria, which is generally accepted to be imminent danger of loss of life or organ function.
If this patient's condition met that criteria, it was not clearly documented. The NAD reference does not imply that the patient had reached that level of severity.