Critical Care documentation

Provider is charging critical care CPT® code 99291. Although time is documented, I'm not sure that this stand alone note clearly supports critical care. Do you agree or disagree? All feedback/guidance is appreciated!


Pt seen in ICU

Sedated (given Ativan in ECC)

Extemely weak

NAD but appears ill

VS tachy @ 110s

BP sl high

Lungs clear

Abd soft NT

Neuro Non focal

Labs reviewed

IV k, PO4, Mg ordered

Serum Acetone, UA ordered

Ethylene glycol, methanol level pos

Discussed with dtrs at length Re:

Condition, Dx, prognosis, POC.

CCT spent 30 min.

re: Critical Care documentation

I don't think this supports critical care because it does not state the patient critical problem like heart failure, respiratory arrest, shock, cardiac arrest etc...anything that shows patient is in danger of losing life. It gives time spent but all 30 min was not with patient

re: Critical Care documentation

I don't believe this documentation supports critical care. Patients in ICU may not always meet critical care coding criteria, which is generally accepted to be imminent danger of loss of life or organ function.

If this patient's condition met that criteria, it was not clearly documented. The NAD reference does not imply that the patient had reached that level of severity.