Checklist: Critical care service
This checklist is intended to provide health care providers with a reference for use when responding to additional documentation requests for critical care services. It is not intended to replace the published guidelines. Health care providers retain responsibility to submit complete and accurate documentation.
| Check |
Documentation description |
|---|---|
| Documentation is for the correct beneficiary and date of service. |
|
| Documentation is complete, legible, signed and dated by the physician or clinician |
|
| Documentation supports medical care for a critically ill or injured patient in which there is acute impairment of one or more vital organ systems, such that there is a probability of imminent or life-threatening deterioration of the patient’s condition. |
|
| Document in the medical record the total time that critical care services are furnished by each reporting practitioner. For concurrent care, services must be sufficiently documented to allow a medical reviewer to determine the role each practitioner played in the patient’s care. |
|
| Documentation supports a medically reasonable and necessary service as outlined in CMS IOM Publication 100-04, Claims Processing Manual, Chapter 12, Section 30.6.12 |
|
| Medical necessity supported by the medical record (e.g., office/progress notes, history and physical, laboratory test results, etc.). |
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| Documentation to support any modifiers billed with the service. |
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| Any additional documentation to support medical necessity or any applicable policy guidelines for the service billed. |
|
| If applicable and required, submitted documentation should include a beneficiary waiver of liability. |
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.