Critical Care Documentation – Full Attention of Physician

Since critical care is a time-based service, the physician ’ s critical care note(s) must document the total time spent evaluating, managing and providing critical care services to a critically ill or injured patient. Critical care time may be continuous or intermittent in aggregated time increments. Time spent performing separately billable procedures/services cannot be used to support critical care time.

The time spent providing critical care services must be spent at the immediate bedside or elsewhere on the floor or unit as long as the physician is immediately available to the patient. Therefore, the physician cannot provide services to any other patient during the same period of time.

Teaching Physician

In the teaching environment, the teaching physician must be present for the entire period of time for which the claim is submitted. Time spent teaching may not be counted towards critical care time. The teaching physician, in addition, cannot bill for time spent by the resident providing critical care services in their absence. Only time that the teaching physician spends with the patient, or that he/she and the resident spend together with the patient, can be counted toward critical care time.

Provided that all requirements for critical care services are met, the teaching physician ’ s documentation may tie into the resident’s documentation. The teaching physician may refer to the resident ’ s documentation for specific patient history, physical findings and medical assessment. NOTE: It is the teaching physician ’ s “ stand alone ” documentation that determines whether a critical care services can be billed.

The teaching physician medical record documentation must provide information including the time the teaching physician spent providing critical care; that the patient was critically ill during the time the teaching physician saw the patient; what made the patient critically ill; and the nature of the treatment and management provided by the teaching physician.

The following is an example of acceptable teaching physician documentation:

Patient seen and examined with Dr. Resident. Reviewed and agree with his note and the plan of care we developed together. One hour of critical care time personally performed due to patient ’ s hemo-dynamic instability. Patient was resuscitated with 2 units of packed red blood cells. Additional studies were obtained to determine possible causes for patient ’ s instabilities.