Principles of critical care documentation

Critical-care service is classified as a provider’s complete delivery of medical care to a critically ill or injured patient with impairment of one or more vital organ systems and a life-threatening condition. Critical care is a time-based service.

  • Time spent with the patient must be documented and must be greater than 30 minutes (e.g., “Patient was seen by (physicians’ name) for critical-care services between 9:20 and 10 am,” or “(Physician’s name) spent 40 minutes with patient.”
  • Activity: What did you do during this time? You must have actively participated in the critical care the patient received.)
  • Most crucial: What system was in failure? The documentation must state failure of a system. Examples include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic and/or respiratory failure. The patient’s condition must be viewed as life-threatening.

Facts to consider:
  • Rendering services on a critical-care floor does not always constitute true critical care. The above criteria must be met to bill the service as critical care.-
  • To bill for critical care, a teaching physician must be present for the entire time period for which the claim is submitted. Time spent teaching may not be counted toward critical-care time.
  • Time spent performing separate reportable procedures or services should not be included in critical-care time.

Codes
  • 99291: Critical Care, first 30-74 minutes (Initial code)
  • 99292: Critical Care, each additional 30 minutes (add-on code)