Critical care documentation - Revision history

Rossdonaldson1 at 19:08, 25 March 2026

2026-03-25T19:08:04Z

← Older revision		Revision as of 19:08, 25 March 2026
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	===Time Calculation===		===Time Calculation===
	*Time spent in critical care activities must ~~'''~~exceed 30 minutes~~'''~~ in order to bill for critical care		*Time spent in critical care activities must exceed 30 minutes in order to bill for critical care
	*'''CPT 99291''' = first 30-74 minutes of critical care time (8.19 RVUs)		*'''CPT 99291''' = first 30-74 minutes of critical care time (8.19 RVUs)
	*'''CPT 99292''' = each additional block of up to 30 minutes beyond the first 74 minutes		*'''CPT 99292''' = each additional block of up to 30 minutes beyond the first 74 minutes
	*Must document either a ~~'''~~specific time~~'''~~ or statement (e.g., "in excess of 30 minutes")		*Must document either a specific time or statement (e.g., "in excess of 30 minutes")
	*Time does '''not''' have to be continuous		*Time does '''not''' have to be continuous
	*Includes: direct patient care at bedside, reviewing test results, discussing case with consultants or family, documenting in chart		*Includes: direct patient care at bedside, reviewing test results, discussing case with consultants or family, documenting in chart
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	==Common Pitfalls==		==Common Pitfalls==
	*Not documenting a ~~'''~~specific critical care time~~'''~~ (must state minutes)		*Not documenting a specific critical care time (must state minutes)
	*Failing to state that time ~~'''~~excludes separately billable procedures~~'''~~		*Failing to state that time excludes separately billable procedures
	*Not documenting the ~~'''~~clinical rationale~~'''~~ for why the patient is critically ill		*Not documenting the clinical rationale for why the patient is critically ill
	*Forgetting to document critical care when managing multiple critical patients simultaneously (each patient's time is counted separately)		*Forgetting to document critical care when managing multiple critical patients simultaneously (each patient's time is counted separately)
	*Under-billing: many ED encounters qualify for critical care billing but are coded at a lower level		*Under-billing: many ED encounters qualify for critical care billing but are coded at a lower level

Danbot: Expanded: added references, RVU info, organized conditions into table with wiki links, added Common Pitfalls, excluded procedures list with links, documentation pages template

2026-03-24T11:02:03Z

Expanded: added references, RVU info, organized conditions into table with wiki links, added Common Pitfalls, excluded procedures list with links, documentation pages template

Show changes

Ashkan.morim: /* External Links */

2021-02-05T19:23:24Z

External Links

← Older revision		Revision as of 19:23, 5 February 2021
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	==External Links==		==External Links==
	*https://www.acep.org/~~Physician-Resources/Practice-Resources/Administration~~/~~Financial-Issues-~~/-~~Reimbursement~~/~~Critical~~-~~Care~~-~~FAQ~~/		*https://www.acep.org/administration/reimbursement/reimbursement-faqs/critical-care-faq/

	==References==		==References==

Mholtz: Text replacement - "w/ " to "with "

2017-07-19T14:47:39Z

Text replacement - "w/ " to "with "

← Older revision		Revision as of 14:47, 19 July 2017
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	==Common Clinical Conditions Consistent with Critical Care==		==Common Clinical Conditions Consistent with Critical Care==
	''Must be first diagnosis''		''Must be first diagnosis''
	*Acidosis w/ aggressive management		*Acidosis with aggressive management
	*Acute Coronary Syndrome (ACS-possible MI) w/ progressive pain management		*Acute Coronary Syndrome (ACS-possible MI) with progressive pain management
	*Active bleed with admit to OR		*Active bleed with admit to OR
	*Anaphylactic shock		*Anaphylactic shock
	*Angina, unstable, aggressive management		*Angina, unstable, aggressive management
	*Atrial fibrillation w/ tachycardia not responding immediately to treatment		*Atrial fibrillation with tachycardia not responding immediately to treatment
	*Asthma, aggressive treatments/frequent monitoring		*Asthma, aggressive treatments/frequent monitoring
	*Comatose/unconscious, unknown cause at presentation		*Comatose/unconscious, unknown cause at presentation
	*COPD/CHF severe exacerbation		*COPD/CHF severe exacerbation
	*Dehydration w/ significant metabolic/ chemistry changes		*Dehydration with significant metabolic/ chemistry changes
	*Head injury, severe, unresponsive		*Head injury, severe, unresponsive
	*Hyperkalemia w/ insulin/bicarb treatment		*Hyperkalemia with insulin/bicarb treatment
	*Hypernatremia w/ mental status change		*Hypernatremia with mental status change
	*Overdose, aggressive treatment, lavage or acute vital sign changes		*Overdose, aggressive treatment, lavage or acute vital sign changes
	*Pneumothorax w/ at least mild/moderate respiratory distress		*Pneumothorax with at least mild/moderate respiratory distress
	*Pulmonary edema or emboli		*Pulmonary edema or emboli
	*Rapid heart rate requiring IV therapies and/or close monitoring in ED		*Rapid heart rate requiring IV therapies and/or close monitoring in ED
	*Seizure, new onset or w/ disorder hx, postictal w/ intensive drug management		*Seizure, new onset or with disorder hx, postictal with intensive drug management
	*Sepsis/septicemia w/ hypotensive management		*Sepsis/septicemia with hypotensive management
	*Severe bleeding requiring transfusion		*Severe bleeding requiring transfusion
	*Shock-unresponsive patient		*Shock-unresponsive patient
	*Status Asthmaticus – defined as patient’s inability to respond during an asthma attack		*Status Asthmaticus – defined as patient’s inability to respond during an asthma attack
	*Status Epilepticus		*Status Epilepticus
	*Stroke, acute, w/ paralysis not just parasthesia		*Stroke, acute, with paralysis not just parasthesia
	*Subdural, subarachnoid, bleeding into the brain		*Subdural, subarachnoid, bleeding into the brain
	*Suicidal ideation, clear & immediate threat, requiring chemical/physical restraints		*Suicidal ideation, clear & immediate threat, requiring chemical/physical restraints

Mholtz at 05:24, 31 May 2017

2017-05-31T05:24:22Z

← Older revision		Revision as of 05:24, 31 May 2017
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	*Trauma, altered consciousness, life or limb threatened		*Trauma, altered consciousness, life or limb threatened
	*Unstable vital signs		*Unstable vital signs


	==See Also==		==See Also==
			*[[Documentation for emergency physicians]]

	==External Links==		==External Links==

Rossdonaldson1 at 00:02, 1 April 2017

2017-04-01T00:02:16Z

@@ Line 19: / Line 19: @@
 ==Sample Documentation==
 :'''Critical Care Procedure Note'''
-:Performed by: ''MD Name''
+:Authorized and Performed by: ''MD Name''
-:Authorized by: ''MD Name''
+:Total critical care time: Approximately ''36'' minutes
-:Total critical care time: ''36'' minutes
+:Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent this critical care time directly and personally managing the patient. This critical care time included obtaining a history; examining the patient; pulse oximetry; ordering and review of studies; arranging urgent treatment with development of a management plan; evaluation of patient's response to treatment; frequent reassessment; and, discussions with other providers.
-:Critical care time was exclusive of separately billable procedures and treating other patients and teaching time.
+:This critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time.
-:Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: ''XX failure''.
+Please see MDM section and the rest of the note for further information on patient assessment and treatment.
-:Critical care was time spent personally by me on the following activities: discussions with consultants, evaluation of patient's response to treatment, obtaining history, ordering and review of laboratory studies and/or x-rays, pulse oximetry, re-evaluation of patient's condition, ordering and performing treatments and interventions, examination of patient, discussions with other provider(s) and development of treatment plan.
 ==See Also==

Rossdonaldson1: /* Sample Documentation */

2017-01-02T18:45:21Z

Sample Documentation

← Older revision		Revision as of 18:45, 2 January 2017
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	==Sample Documentation==		==Sample Documentation==
			:'''Critical Care Procedure Note'''
			:Performed by: ''MD Name''
			:Authorized by: ''MD Name''
			:Total critical care time: ''36'' minutes
			:Critical care time was exclusive of separately billable procedures and treating other patients and teaching time.
			:Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: ''XX failure''.
			:Critical care was time spent personally by me on the following activities: discussions with consultants, evaluation of patient's response to treatment, obtaining history, ordering and review of laboratory studies and/or x-rays, pulse oximetry, re-evaluation of patient's condition, ordering and performing treatments and interventions, examination of patient, discussions with other provider(s) and development of treatment plan.

	==See Also==		==See Also==

Mholtz at 22:28, 24 December 2016

2016-12-24T22:28:59Z

← Older revision		Revision as of 22:28, 24 December 2016
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	==Background==		==Background==
			*Delivery of critical care is common in the ED setting.
	*Multiple components must be satisfied and appropriately documented in the medical record when delivering critical care in the ED.		*Multiple components must be satisfied and appropriately documented in the medical record when delivering critical care in the ED.

	===Elements of Critical Care Time===		==Elements of Critical Care Time==
	*'''Critical illness or injury''' = illness or injury that impairs one or more "one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.”		*'''Critical illness or injury''' = illness or injury that impairs one or more "one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.”
	*'''Critical care services''' = direct medical care for the patient that involves “high complexity decision making to assess, manipulate, and support vital organ system failure.”		*'''Critical care services''' = direct medical care for the patient that involves “high complexity decision making to assess, manipulate, and support vital organ system failure.”
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	*'''Time''' = total time spent evaluating, managing, and providing care to a critically ill patient. Does not have to be continuous. Includes direct patient care at bedside as well as time spent reviewing test results, discussing the case with consultants or family members, and documenting in the patient's chart.		*'''Time''' = total time spent evaluating, managing, and providing care to a critically ill patient. Does not have to be continuous. Includes direct patient care at bedside as well as time spent reviewing test results, discussing the case with consultants or family members, and documenting in the patient's chart.

	==~~Critical Care Diagnoses~~==		===Time Calculation===
	~~The following diagnoses may qualify~~ for ~~documenting~~ critical care time:		*Time spent in critical care activities must exceed 30 minutes in order to bill for critical care time.
	*~~Active Seizures / [[Status Epilepticus]]~~		**CPT Code 99291 is used for the first 30-74 minutes of critical care time
	*~~Acute [[Altered Mental Status]] / Unconscious~~		**CPT Code 99292 is used for additional blocks of time of up to 30 minutes beyond the first 74 minutes of critical care time
	*~~[[Gastrointestinal bleeding\|Acute GI Bleed]]~~		*Must document either a specific time or, e.g., "in excess of 30 minutes".
	*~~[[Stroke (main)\|Acute Stroke]]~~		*Calculated time must exclude all separately billable procedures
	*~~[[Anemia]] requiring transfusion~~		**These include (but are not limited to): central line or transvenous pacemaker placement, chest tube placement, endotracheal intubation, CPR.
	*~~[[Atrial fibrillation with RVR\|A fib with RVR]]~~
	*~~[[ACLS~~ (~~Main)\|Cardiac Arrest]]~~
	*[[Delerium tremens]]
	*[[Diabetic ketoacidosis\|DKA]]
	*[[Ectopic pregnancy]]
	*[[Hyperkalemia]] requiring acute intervention
	*[[Undifferentiated shock\|Hypovolemic shock]]
	*[[Hemorrhagic stroke\|Intracerebral Hemorrhage]]
	*Moderate to Severe [[Asthma]]
	*Moderate to ~~Severe [[Congestive heart failure\|CHF]]~~
	*[[Toxicology (main)~~\|Overdose requiring reversal agents]]~~
	*[[Pneumothorax]]
	*[[Pulmonary embolism]]
	*[[Shortness of breath\|Respiratory distress]] requiring BiPAP or intubation
	*[[Sepsis]]
	*[[STEMI]]
	*Suicidal ideation with immediate threat
	*[[Paroxysmal supraventricular tachycardia\|SVT]]
	*[[Unstable angina]]

	==Sample Documentation==		==Sample Documentation==

Mholtz at 22:13, 24 December 2016

2016-12-24T22:13:30Z

← Older revision		Revision as of 22:13, 24 December 2016
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	==Background==		==Background==
	*~~CMS notes that~~ critical care ~~is considered when "the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration~~ in the ~~patient's condition."~~		*Multiple components must be satisfied and appropriately documented in the medical record when delivering critical care in the ED.
	*Time providing care must be at least 30 minutes and must be documented. This must be exclusive of separately-billable procedures.

	~~==Measuring Critical Care Time==~~

			===Elements of Critical Care Time===
			*'''Critical illness or injury''' = illness or injury that impairs one or more "one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.”
			*'''Critical care services''' = direct medical care for the patient that involves “high complexity decision making to assess, manipulate, and support vital organ system failure.”
			**CMS additionally mandates that for medicare patients, "the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient's condition".
			*'''Time''' = total time spent evaluating, managing, and providing care to a critically ill patient. Does not have to be continuous. Includes direct patient care at bedside as well as time spent reviewing test results, discussing the case with consultants or family members, and documenting in the patient's chart.

	==Critical Care Diagnoses==		==Critical Care Diagnoses==

Mholtz: Mholtz moved page Critical Care Documentation to Critical care documentation

2016-12-24T20:27:13Z

Mholtz moved page Critical Care Documentation to Critical care documentation

← Older revision	Revision as of 20:27, 24 December 2016
(No difference)