Appropriate Medical Record Documentation for Critical Care Services
In September, Cahaba GBA published an article concerning the documentation and billing of critical care services. Cahaba provided the information in response to documentation errors identified by data analysis and medical record review.
“In a hospital outpatient setting, CPT 99291 (critical care, first 30-74 minutes) is used to report the services of a physician and/or hospital staff providing full attention to a critically ill or critically injured patient from 30-74 minutes on a given date.”
Key points of the article included:
- Documentation should support that the patient’s condition warranted the type and amount of services provided.
- Documentation should support that the physician and/or hospital staff were providing face to face care to the critical patient
- The amount of time spent providing critical care must be documented in the medical record
- CPT code 99291 is for 30-74 minutes of critical care time; critical care of less than 30 minutes should be reported using another appropriate E&M code
- Only one unit of CPT code 99291 may be billed by a hospital per patient per day of service
- Certain services (identified in the CPT manual) are bundled into critical care services and are therefore not separately billable
MMP, Inc. also reminds hospitals that per the Correct Coding Initiative manual, time spent performing CPR can not be counted toward the time for critical care services. CPT code 99292 may be billed in addition to 99291 for critical care services lasting longer than 74 minutes.
The complete article on critical care services can be viewed on the Cahaba website at this link: Cahaba GBA Critical Care Services Article