Critical Care Audit Worksheet

Critical Care Documentation and Audit WorksheetCritical care billing and documentation is intimidating to many healthcare providers.  The rules are not as detailed as the 1997 E&M Guidelines issued by CMS, and there is room for interpretation of what qualifies as a critical illness.

Clear, complete, and concise medical documentation is essential to providing patients with high quality and safe medical care. Medical documentation is also essential for accurate and timely payment for healthcare services. Qualifying for payment requires skillful application of the documentation guidelines for critical care services published by the Center for Medicare and Medicaid Services (CMS). 

This critical care audit worksheet includes the basic rules for critical care documentation, instructions on how to bill the time defined critical care codes, and a list of medical procedures that are bundled into critical care services.



What needs to be documented in a critical care note?

To qualify for billing critical care services, your encounter note needs to include documentation of the nature of the critical illness or injury, the presence of the provider at the patient’s bedside or hospital unit, and the time spent evaluating and stabilizing the patient.  Failure to document the time spent with the patient is probably the most common reason charges for critical care services are rejected by insurers. 


This critical care documentation worksheet is useful for anyone learning how to bill for critical care services or anyone who wishes to check to make sure their documentation meets all the rules set by Medicare for critical care services.

Download your free copy of this critical care documentation worksheet by clicking on the PDF icon below.

Download your free copy of this critical care audit worksheet

How can I use this Critical Care cheat sheet to improve medical billing?

Using this Critical Care Coding Tool will give you the confidence to bill for critical care services and will help with the question of how many CPT codes to bill for each patient.  This will maximize your clinical revenue and may help you identify ways to improve your documentation to reduce your RAC audit risk and speed payment under Concurrent Review.

Requirements to use this Critical Care Coding Worksheet

This medical coding worksheet is in the Adobe PDF format, which requires the free Adobe Reader to function. With Adobe Reader, these worksheets can be  printed as many times as you need.

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