Fortunately, the Centers for Medicare & Medicaid Services (CMS), the American Medical Association (AMA), and other specialty societies publish a lot of guidance on critical care documentation. Although there are multiple facets to critical care billing, this article is focused on the one thing I repeatedly find lacking in charts: medical necessity.
I think we have all seen this verbiage, but have you paused to consider the implications? When coding a critical care chart, we often look for the key documentation points, such as time spent performing critical care, what made the patient critically ill, and the nature of the treatment provided by the provider. However, in doing chart reviews, I still find myself asking the question, is the definition of critical care being met? What I usually find missing or unclear is what organ system is at risk.
Going back to the definition of critical care, does the documentation support that the critical illness or injury puts an organ system at risk? Often critical illness or injury is documented, with no correlation to an organ system. For example, the documentation may say the patient is critically ill due to a traumatic brain injury or blunt abdominal trauma. Does blunt abdominal trauma mean renal failure? Hepatic failure? Or both? Does this also suggest that every patient with a TBI or trauma requires critical care? These are the hard questions we need to be asking.
While the critical care guidelines do not specify that documentation must state the organ system, how else is there proof that the definition of critical is being met? To that end, I encourage the documentation to go beyond stating the critical illness and correlate it to an organ system. For example, instead of documenting that the patient is critically ill due to TBI, state that the patient is critically ill due to the risk of permanent neurological system damage from the TBI.
Check out our tips below and be sure to consider other critical care components, such as documenting time and provider interventions. In addition, I encourage you to review all the reference links provided!
Documentation Tips for Providers:
- Document how much time you spent performing critical care, exclusive of time spent performing separately billable procedures.
- Document what vital organ system is failing or threatened.
- Document what interventions are being done to support or prevent vital organ system failure.
- Instead of documenting the patient is critically ill due to an illness or injury, specify the organ system(s);
- Example – Intracranial hemorrhage, neurological system is affected, and that monitoring and medications are given to prevent permanent neurological failure or impairment.
- Example – Patient critically ill for the last 24 hours. He has developed diabetic ketoacidosis and septic shock due to acute pyelonephritis, now with acute renal failure.
- Watch for discrepancies in documentation.
- Does the resident state the patient is ambulating, stable on room air, or that other conditions are stable or resolving?
Is your organization in compliance with your documentation? You can view the OIG's updated hit list in the references below. Avoid the hit and get ahead of the OIG with a Haugen Consulting Group audit. Contact us today to learn more about our services.
2020 AMA CPT Professional
Deanna Upston, CPMA, CPC, COSC