tci ED Coding & Reimbursement Alert - 2017 Issue 5

Critical Care: Is That High Acuity ED Presentation Critical Care or Not?

Check for documented time and acuity of the presenting problem to inform your critical care choice. Critical care coding is different from the ED E/M services in that it does not have the traditional documentation requirements for history, physical exam, and medical decision making; however that can make it harder for coders to determine when the threshold for reporting critical care is achieved. CPT® is clear about the required time units that must be documented, but how do you determine if the patient is really critically ill or injured based on chart documentation? These common ED case examples will...

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