Critical care documentation
Background
- CMS notes that critical care is considered when "the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient's condition."
- Time providing care must be at least 30 minutes and must be documented. This must be exclusive of separately-billable procedures.
Measuring Critical Care Time
Critical Care Diagnoses
The following diagnoses may qualify for documenting critical care time:
- Active Seizures / Status Epilepticus
- Acute Altered Mental Status / Unconscious
- Acute GI Bleed
- Acute Stroke
- Anemia requiring transfusion
- A fib with RVR
- Cardiac Arrest
- Delerium tremens
- DKA
- Ectopic pregnancy
- Hyperkalemia requiring acute intervention
- Hypovolemic shock
- Intracerebral Hemorrhage
- Moderate to Severe Asthma
- Moderate to Severe CHF
- Overdose requiring reversal agents
- Pneumothorax
- Pulmonary embolism
- Respiratory distress requiring BiPAP or intubation
- Sepsis
- STEMI
- Suicidal ideation with immediate threat
- SVT
- Unstable angina