decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Critical Care Services / Time With Family Members Okay for Critical Care
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Article Overview
This short article addresses Medicare guidance on documenting critical care services when time is spent with family members or surrogate decision makers to obtain a history or discuss treatment options. It is relevant to physicians, coders, and compliance staff who need to understand the general documentation elements Medicare expects for this type of critical care time.
Why This Topic Matters
Correct documentation can affect whether critical care time is supported in the record and helps reduce risk in claim review or audit situations.
What You Will Learn
- The documentation elements Medicare expects when family discussions are used as part of critical care time
- The types of situations in which surrogate or family-member communication is relevant to critical care documentation
- How this guidance relates to physician progress note documentation for the day of service
- That phone discussions with family members and surrogate decision makers are addressed under the same general documentation expectations
Who Should Read This
- Physicians
- Medical coders
- Clinical documentation specialists
- Compliance staff
- Revenue cycle staff
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