Critical care documentation

Hi,
Please clarify me on whether for a physician to bill out a 99291 should the term " critical care" be
mentioned in his documention.

eg 1: can we code a 99291 if the physician states " i have spent 45 minutes in consultation, reviewing old records, lab results of the patient"


eg 2: can we bill a 99291 if the physician states that " i have spent 30 minutes in exclusve care of the patient.

Please let me know

how should the physician document ? should the exact words " critical care" be mentioned?

Thnakyou so much

re: Critical care documentation

I used to work in a hospital and billed for the hospital based physicians and they always put "spent 45 minutes in critical care with the patient".

re: Critical care documentation

MUST say critical care or you'd use the time based coding for E&M. And just because they say critical care does not mean the auditor will agree the patient was critically ill, but that's a separate issue...

re: Critical care documentation

Thank you so much for your reply