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Checklist: Critical care

This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for critical care services.

It is the responsibility of the practitioner who provided the services to ensure the correct submission of documentation. 

Check Documentation description
  Complete and legible medical record documentation should be submitted.
  Should include specific documentation that may have been requested.
  Medical records for the date(s) of service(s) and specific patient (name and date of birth) on the claim under review.
  Ensure the medical record submitted supports the service(s) that was (were) ordered and/or rendered.
 

To support the level of service (code) / complexity, include documentation to address the following:

  • Chief complaint
  • Severity of illness
  • Intensity of services required to treat the illness
  • History
  • If history is taken by ancillary staff, ensure the billing practitioner indicates this was reviewed
  • Physical exam
  • Medical decision-making
  • Any additional documentation that may support medical necessity of the level of service(s) billed
 

Medical records should justify that the service was medically reasonable and necessary for the diagnosis/treatment of the injury or illness, and should include:

  • Physician's progress notes
  • Initial history and physical
  • Physician's orders
  • Procedure notes
  • Assessment, clinical impression, or diagnosis
  • X-ray, diagnostic test and laboratory results
  • Medical plan of care
  • Legible signatures of professionals providing services
 

Documentation based on counseling or coordination of care to include:

  • Total time providing critical care services
  • Critical care should include start / stop time.
  • Amount, or percent, of time involved in counseling or coordination of care.

  • Description of the discussion.

    Note: Time alone does not determine the level of service. Documentation must support the complexity of the level of service billed.
  Note: Services cannot be billed as critical care based solely on being provided in a critical care setting such as Intensive Care Unit (ICU).

 

Disclaimer 
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.