tci ED Coding & Reimbursement Alert - 2013 Issue 4

Critical Care Coding: Are You Documenting Your Critical Care Time Accurately?

Check out these resources to see if your policies are in order. Every ED coder knows critical care is a time based code. But there can be some confusion about what documentation is required to justify the time reported. Where do you turn for definitive direction? Key resources: The most obvious places to look are the CPT® book and the Medicare Claims Processing Manual. Per CPT®, “Time spent with the individual patient should be recorded in the patient’s record” and the CMS manual tells us that “the physician’s progress note(s) shalldocument the total time that...

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