Critical Care documentation

Provider is charging critical care cpt code 99291. Although time is documented, I'm not sure that this stand alone note clearly supports critical care services. Do you agree or disagree?

Pt seen in ICU

Sedated (given Ativan in ECC)

Extemely weak

NAD but appears ill

VS tachy @ 110s

BP sl high

Lungs clear

Abd soft NT

Neuro Non focal

Labs reviewed

IV k, PO4, Mg ordered

Serum Acetone, UA ordered

Ethylene glycol, methanol level pos

Discussed with dtrs at length Re:

Condition, Dx, prognosis, POC.

CCT spent 30 min.

All feedback/guidance is appreciated!

Critical Care documentation