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Does My Documentation Tell the Story in Critical Care?

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The initial and subsequent hospital codes 99221-99233 require specific documentation of the key components: history, examination, and medical decision-making. The contributing factors are counseling, coordination of care, the presenting problem(s), and time. In critical care, documentation requirements are not spelled out in as much detail as they are for non-critical care, which prompts the question, What do I need to document to support billing my critical care services?
The rule of thumb is to tell the story. You do not have to follow the documentation requirements for hospital services but, if you can formulate a template that covers some of these elements, it helps tell the story. One of the biggest problems with documentation in critical care is that it does not always explain why the patient’s status is critical. The first important piece of the documentation is the chief complaint. Just stating the reason that the patient’s status is critical is the first step in good documentation. Documentation should paint a picture of the patient’s condition. The chief complaint will drive the entire patient encounter. It is important to document a chief complaint for all critical care encounters, not just for the initial encounter.
For the initial encounter, it is important to provide more detail, such as the history of the present illness, a focused review of systems, past medical history, and family and social history. If the patient is unable to provide this information, a family member or previous medical records may be able to fill in the gaps.
The practitioner should always document an examination relative to the patient’s condition. Any laboratory and diagnostic testing, bedside procedures, and other activities should be well documented. Any treatment discussion with family members or caregivers should be documented. The assessment should outline all conditions managed, any comorbidities that affect the patient’s care, and the status of the patient’s condition.
Subsequent encounters should also contain a brief chief com-plaint, the status of the patient’s condition, a focused examination, tests ordered, procedures per-formed bedside, other activities, and patient and family discussions. The assessment should always contain the status of the patient’s condition (eg, improving, worsening, failing to change) along with comorbidities that affect the patient’s care.
For both the initial and all subsequent encounters the plan of care should reflect treatment decisions and the medical necessity for the encounter to support a high level of complex medical decision-making. If a diagnostic test, intervention, or procedure is planned or anticipated, it should also be documented. “Continue same plan” does not tell the story; the plan should be restated or summarized for every visit after the initial encounter.
Since critical care services for children older than 5 years and adults (99291-99292) are time-based codes, the total duration of time must be documented. Some payers prefer start and stop times while others are satisfied with the total duration of time for each encounter. It is important to check your payer’s requirements. Do not forget to add the time for the entire calendar day if multiple visits were necessary to manage the patient’s critical care.
Neonatal and pediatric critical care (99468-99469, 99471-99472, 99475-99476) is reported per calendar day. The same documentation recommendations apply to pediatric critical care with the exception that time does not need to be documented for neonatal and pediatric CPT codes.
Documentation should paint a picture of the patient’s condition. Medical necessity drives every patient encounter. In fact, the Comprehensive Error Rate Testing (CERT) Program states, “Medical necessity of a service is the over-arching criterion for payment in addition to the individual requirements of a CPT code.” Diagnosis coding is very important for any specialty but especially important when managing a critical care patient. Coding and documentation should tell the payer what and why—what services are performed and the reason for providing the service.
Critical care documentation should always include:

  • Why the patient’s stat us is critical
  • The organ system(s) at risk
  • An examination relative to the patient’s condition
  • Which diagnostic and/or therapeutic inter vent ions were performed, including rationales for performing them
  • Critical findings of laboratory tests, imaging, ECG, etc., and their significance
  • Course of treatment (plan of care)
  • Likelihood of life-threatening deterioration without intervention
Understanding that complete documentation plays a key role in supporting the high complexity of critical care is important when billing for this service. Medical necessity should be the driving factor when determining whether a patient’s care meets the defini-tion of critical care.
Also note that a shared visit between an advanced practice provider and a physician is not allowed for critical care services.
Make sure that, at least once per year (and recommended more frequently than that), each practitioner who bills critical care should undergo an internal audit to identify problem areas and pro-vide guidance to ensure clinical documentation improvement.