tci Part B Insider - 2013 Issue 11

Part B Coding Coach: Are You Documenting Your Critical Care Time Accurately?

Check out these resources to see if your policies are in order.     Every 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) shall document the total time that critical...

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