E/M Coding Alert - 2016 Issue 2
Reader Question: Watch the Clock When Reporting Both Critical Care and CPR
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Article Overview
This reader question explores time-based critical care reporting in an emergency department scenario involving resuscitation, airway management, and documentation of family discussions. It is aimed at clinicians, auditors, and coding professionals who need to understand how narrative documentation and separately billable procedures can affect whether reported critical care time is supportable. The article also references CPT guidance on family or surrogate conversations and mentions other common contributing activities that may be documented during a critical care encounter.
Why This Topic Matters
Accurate critical care reporting depends on distinguishing time spent in separately billable procedures from time that may count toward critical care, especially in complex resuscitation cases. Clear documentation can affect audit outcomes and whether reported time is defensible.
Article Sections
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Question
Introduces a coding and documentation concern involving critical care time in an emergency department encounter with resuscitation-related services.
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Answer
Discusses general considerations for evaluating reported critical care time when multiple services and family discussions occur during the encounter.
What You Will Learn
- How critical care time is evaluated when other services occur during the same encounter
- Why documentation of family or surrogate discussions may affect time-based reporting
- What types of supporting activities may be relevant in a critical care review
- Why separately billable procedures can complicate time calculations in emergency care
Who Should Read This
- Physicians
- Emergency department clinicians
- Medical coders
- Coding auditors
- Compliance staff
- Revenue cycle professionals
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