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Critical Care Documentation Tips For Physicians

Critical Care Documentation Tips for Physicians

Part of a recurring series on documentation guidance provided by Dr. Robert Wagner, MedData’s Senior Vice President of Medical Affairs.

When Can I Document Critical Care?

  • Any patient that requires your immediate attention should be considered for critical care. Often these patients have one or more vital organ systems impaired. Even if your patient improves after treatment, if you spent 30 minutes or more providing care that prevented your patient from deteriorating into a life-threatening situation, this would qualify as critical care.

How Is Critical Care Defined?

  • A critical illness or injury is one that acutely impairs 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 are defined as a physician’s (or NPP’s) direct delivery of medical care for a critically ill or critically injured patient. It involves decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition.

How Should I Apply Time-Based Code?

  • Report the time you spent evaluating, managing, and providing the patient’s care including reviewing lab tests, discussing with consultants and family, and documentation.
  • There must be at least 30 minutes of Critical Care time.
  • Document an exact time rather than a time frame.

What Are the Requirements to Qualify as Critical Care?

  • Are there one or more vital organs impaired?
  • Is there a high probability of imminent or life-threatening deterioration in the patient’s condition?
  • Did you have to intervene to prevent further life-threatening deterioration?

What Are Some Common Diagnoses Associated with Critical Care?

(Not a comprehensive list)

  • Acute MI/Unstable Angina/Acute Coronary Syndrome
  • AAA
  • CVA (even if you consider TPA and do not administer)
  • Respiratory Distress/Failure/Hypoxia
  • Sepsis
  • Cardiac Arrest
  • DKA
  • Hyperkalemia
  • Altered Mental Status
  • GI Bleed
  • Meningitis
  • Rhabdo
  • Cervical Spine Injury
  • Neonatal fever with septic workup
  • Drug ingestion/Overdose
  • Shock of any type
  • Multisystem Trauma

What Are Some Common Medications Associated with Critical Care?

(Not a comprehensive list)

  • IV Beta Blockers
  • IV Calcium Channel Blockers
  • Other IV antiarrhythmics
  • IV Nitroglycerin
  • IV Insulin
  • Vasopressors (Levophed, etc.)
  • Paralytics
  • Thrombolytics
  • Narcan

What Are Some Common Procedures Associated with Critical Care?

(Not a comprehensive list)

  • Intubation/BiPap
  • Central Venous Access
  • Ventilator Management
  • Thoracostomy tube
  • Cardioversion
  • Lumbar Puncture

Robert J. Wagner, MD, FACEP

Dr. Robert Wagner is the Senior Vice President of Medical Affairs at MedData. He has worked with healthcare organizations of all sizes, building consensus to integrate the revenue cycle, IT, coding, compliance, informatics, and care and utilization management to provide sound clinical, operational, and financial outcomes. Dr. Wagner is passionate about making sure patients receive excellent care – clinically and financially. He has helped multiple clients build end-to-end revenue cycle solutions, removing the challenges and ensuring patients and providers have a data-driven, compliant, and integrated financial experience.

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