Documentation Tip

Documentation Tip: Critical Care

Documentation Tip: Critical Care

Critical care is defined as a “high probability of sudden, clinically significant, or life threatening deterioration.” It requires the highest level of preparedness to intervene urgently. There is no one more prepared to intervene urgently than the emergency physician. This defines the specialty.

It involves direct personal management (this does NOT require bedside care), the absence of which would likely result in sudden, clinically significant or life threatening deterioration. Critical care no longer requires unstable vital signs. If you do nothing for the patient what is the potential that the patient could have a critical result? If that probability is high, critical care is in play.

When a patient receives aggressive management in the ED such as intubation, CPR, etc. it is NOT difficult to support critical care services. CPT clearly states what is included in critical care time such as reviewing test results or imaging studies, discussing the patients care with other healthcare providers and documenting in the patient’s medical record, most of which is provided away from the patient’s bedside.

In the case of a patient that is unable to participate in discussions, time spent with family members or other surrogate decision makers to obtain history and discuss treatment or DNR wishes may be reported as part of the critical care service provided to the patient. It is important to document WHY the patient required critical care services. Document what organ system has the potential for immediate deterioration and WHY. State the time spent providing critical care (excluding time spent performing separately billed procedures or services). You might use a phrase such as: “Care between ___ and___ minutes was performed in order to assess and manage the high probability of imminent or life-threatening deterioration to __(organ or function)__ involving ( interventions) with frequent reassessment”.

To bill for critical care the physician must have provided at least 30 minutes of CC time excluding the time spent performing separately billable services such as ECG interpretations, central line placement, intubation or CPR. It is not possible to know the exact amount of time spent providing cognitive services to a patient but you must document your best estimate of time such as: “approximately 40 minutes” or a range such as “35-40 minutes of CC time.

Common Clinical Conditions Consistent with Critical Care

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

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