CMS Pub. 100-04, ch. 12, § 30.6.12.8

Critical care is a time-based service, and therefore, practitioners must document in the medical

record the total time (not necessarily start and stop times) that critical care services are

furnished by each reporting practitioner. Documentation needs to indicate that the services

furnished to the patient, including any concurrent care by the practitioners, are medically

reasonable and necessary for the diagnosis and/or treatment of illness and/or injury or to

improve the functioning of a malformed body member.

To support coverage and payment determinations regarding concurrent care, services must be

sufficiently documented to allow a medical reviewer to determine the role each practitioner

played in the patient’s care (that is, the condition or conditions for which the practitioner

treated the patient).

When critical care services are reported the same date as another E/M visit, the medical record

documentation must support: 1) that the other E/M visit was provided prior to the critical care

services at a time when the patient did not require critical care, 2) that the services were

medically necessary, and 3) that the services were separate and distinct, with no duplicative

elements from the critical care services provided later on that date.

When critical care services are furnished in conjunction with a global procedure, the medical

record documentation must support that the critical care was unrelated to the procedure, as

discussed above.

To support coverage and payment determinations regarding split (or shared) critical care

services, the documentation requirements for all split (or shared) E/M visits apply to critical

care visits also (see section 30.6.18).