Outpatient Facility Coding Alert - 2015 Issue 7
Reader Questions: Is It Critical For The Physician To Document A Full History For Code 99291?
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Article Overview
This reader Q&A explains the documentation focus for critical care billing in physician services and compares it with emergency department E/M reporting. It is aimed at coders, billers, and clinicians who need to understand the general documentation and time-based considerations discussed for these services.
Why This Topic Matters
Understanding how critical care documentation differs from emergency department E/M documentation can help readers assess whether a chart supports the service category being reported and what general elements the physician record should reflect.
Article Sections
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Question
The reader asks about the level of history, review, examination, and other chart elements needed for critical care reporting in the emergency department setting.
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Answer
The response compares critical care documentation expectations with emergency department E/M requirements and highlights the general time-based nature of critical care reporting.
What You Will Learn
- How critical care documentation is discussed in relation to emergency department E/M services
- What general chart elements are emphasized for critical care reporting
- Why time plays a central role in the service discussed
- How critical care and ED E/M documentation requirements differ at a high level
Who Should Read This
- Medical coders
- Billing staff
- Physicians
- Clinical documentation specialists
- Revenue cycle professionals
Codes Discussed
Code Ranges Discussed
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