Critical Care
Critical Care Note
My critical care time involved full attention to the patient’s condition and included:
-Review of nursing notes, old records, and OSH records when available
-Review of patient history, including discussion with patient, family, EMS when available
-Documentation time
-Discussion of case with patient, family, nursing staff, consultants, admitting team
-Ordering, interpreting, and reviewing laboratory and diagnostic studies
Justification:
-Risk factors: [HTN Emergency, Respiratory failure, Trauma Activation, etc…]
-Interventions/Rationale: See MDM/re-exams for details. Data reviewed, discussed with consultants, repeat exams. This patient has a foreseeable threat of multiple organ system failure and possible death without critical care.
-Procedures performed: []
Total critical care time, independent of procedures performed and teaching time: [30mins]
Performed by: Self
- Last updated January 26, 2023
Charting Tips
- Use the “risk factors” section to justify why your patient qualifies for critical care. For example “Risk factors: Airway compromise requiring intubation, on pressers, ICU admit.” Think of this section as the “MDM” of your critical care note.
- Remember critical care time is billed in increments of 30 minutes. The initial 30-74mins is coded under 99291. Each additional 30 mins after this is coded as 99292.
- It is important to remember that critical care time involves not just time at the bedside, but also time with consultants or family, time reviewing records/labs/rads, time charting, etc…Basically any time you use brain power dedicated to that patient
- CC time DOES NOT include time teaching or procedures including things like CPR(don’t worry, we have a CPR note).