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Critical Care Services: CPT Codes 99291-99292

Definition

CMS defines critical care as “the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient” and also defines a critical illness or injury as one that “acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.” In the final segments of this article, we have included several examples of critical care situations, provided by CMS.

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Context

Critical care may be delivered outside the context of acute clinical crisis, but always requires the imminent risk of further deterioration in a critically ill or injured patient. Factors that are expected in the critical care context are:

  • Highly complex clinical decisions, usually based on interpretation of complex data and use of advanced technology
  • Clinical decisions addressing organ system failure, or the prevention of further life-threatening deterioration
  • Both the clinical status and the care rendered by the provider are critical in nature
  • All reasonable sites of service are permissible when the clinical condition, the intensity of care and the time spent meet the critical care definition

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Providers Who May Perform Critical Care

Physicians and qualified NPPs may provide critical care services when care meets the definition and requirements for such services. Provision of these services must be within each provider’s scope of practice and licensure for the state in which the provider is practicing.  A PA must meet the general physician supervision requirements for the services.

Unlike other hospital-based services, critical care cannot be performed on a split/shared basis, and each unit of care must be rendered and billed by a solitary provider. Critical care reflects treatment and management by an individual physician or qualified NPP for the documented time period supporting the service. Individual units of critical care time can be reported by separate same-specialty providers within a group over the course of a 24-hour period, meaning that a base unit of 99291 can be billed with subsequent units of 99292 by other group members. When a physician or qualified NPP within a group provides “staff coverage” or “follow-up” for each other, after the first hour of critical care on the same calendar date, the subsequent visit by the covering provider (physician or NPP) may be billed with the critical care add-on code 99292. The subsequent visit should be billed with the NPI of the provider performing the subsequent service.

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Services and Medical Necessity

As with all services approved by Medicare, critical care must be reasonable and necessary, based on the provider’s assessment of a clinical crisis and/or imminent deterioration requiring immediate intervention.

Situations which do not support the necessity of critical care include:

  • Care for patients in a critical, intensive or specialized care unit who are clinically stable and responding favorably to established interventions. Subsequent hospital care codes (99231-99233) may be more appropriate in these circumstances
  • Chronic long term management of patients who are ventilator or dialysis dependent, unless a change in condition threatens the patient’s clinical stability and demands immediate intervention
  • Patients admitted to a critical care unit because no other hospital beds were available

Situations that may not satisfy Medicare medical necessity criteria for critical care services:

  • Patients admitted to a critical care unit for close nursing observation and/or frequent monitoring of vital signs (e.g., drug toxicity or overdose)
  • Patients admitted to a critical care unit because hospital rules require certain treatments (e.g., insulin infusions) to be administered in the critical care unit.
  • Care for a critically ill patient that is not critical in nature (e.g., dermatological treatment of a minor skin rash for an acutely ill ICU patient)

Note:  It is the physician’s or NPP’s documentation of the patient’s condition and services rendered, not the location  that determines whether critical care is appropriately billed.

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Palliative and Hospice Patients

Critical care services are intended to assess, manipulate and support vital organ system failure, and to prevent further life threatening deterioration.  These services are appropriate when critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition. 

While there are multiple definitions of palliative care, NGS follows the World Health Organization’s definition of palliative care as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” 

Organ failure and associated deterioration are integral to the clinical course of patients receiving palliative care, and the physician’s role in such circumstances is generally defined by pain management, counselling and overall relief of symptomatology.

Critical care may rarely be appropriate in the palliative care environment. It may be permissible when an unexpected and acute emergency arises in a hospice patient. In such rare instances, medical record documentation would be expected to support the nature of the clinical problem and the intervention performed by the billing provider.

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Full Attention of the Provider and Provider Time Assessment and Documentation

Critical care services are represented by time-based codes, so providers must monitor and document time spent carefully. Time should be documented as spent (e.g. “70 minutes”) or as clock time (e.g. “8:30 am-9:45 am”). Subjective statements (e.g. “spent a long time with patient and family” or “had a lengthy discussion”) are not acceptable as time documentation.

Time that can be counted includes time spent by the provider in evaluating, treating and managing the patient’s condition, both at the bedside and on the unit while coordinating care, as long as the provider remains immediately available to the patient. Unit time may include review of diagnostic and laboratory findings and discussion with colleagues regarding the patient’s management.  Time spent off the unit cannot be counted, since the provider is not immediately available to the patient. In addition, teaching sessions with hospital residents, often performed during rounds, do not count toward critical care time.

Critical care service time must be exclusive to the patient, meaning the provider cannot perform services for other patients during the same timeframe.

Each critical care progress note must include total time spent by the provider while performing the service. Critical care may be provided on the same day (but not during the same time segment) by providers representing different specialties, each of whom must carefully document his/her own role in the care and the time spent. Non-continuous time for medically necessary critical care services may be aggregated over a 24-hour period.

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Family Counseling and Discussion

When patients are critically ill, providers often routinely discuss daily updates with family members or healthcare proxies. Time spent for these updates is considered part of the pre and post service work of critical care service, and does not count toward time spent in actual critical care delivery.

In the following circumstances, face-to-face discussions with family members or proxies can be counted as critical care time. Documentation must reflect the patient’s inability to participate when:

  • Provider is obtaining a history and the patient is unable or incompetent to participate
  • Discussion is considered medically necessary in determining treatment decisions

Note:

  • No other family or proxy discussions, no matter how lengthy, count toward critical care time
  • Telephone calls with family or proxies may count toward critical care time, but only when they meet the above criteria (obtaining history and/or determining treatment decisions) and are documented as such.

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Bundled vs. Nonbundled Services

The following is a list of procedures that are considered bundled into critical care. Time spent performing these services is included in critical care time and these services should not be billed separately from the critical care codes:

Procedure CPT Code
The interpretation of cardiac output measurements 93561, 93562
Chest x-rays, professional component 71010, 71015, 71020
Blood draw for specimen 36415
Blood gases, and information data stored in computers
(e.g., ECGs, blood pressures, hematologic data)
99090
Gastric intubation 43752, 91105
Pulse oximetry 94760, 94761, 94762
Temporary transcutaneous pacing 92953
Ventilator management 94002 - 94004, 94660, 94662
Vascular access procedures 36000, 36410, 36415, 36591, 36600

Procedures not identified on this list are not bundled into critical care and may be billed separately when medical necessity expectations are met and there is proper documentation. 

In addition, please note that time spent performing nonbundled procedures (e.g. spinal tap, endotracheal intubation) cannot be counted toward critical care time, since these procedures are separately billable and payable.

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Billing Considerations

Critical care is a time-based service, performed on an hourly or fraction of an hour basis. Payment is not restricted to a fixed number of hours, providers or days as long as services meet medical necessity standards. The following CMS guidelines apply:

  • Critical care time may be aggregated over a 24-hour period
  • Only one physician may bill for critical care services during any one single period of time even if more than one physician is providing care to a critically ill patient.
  • Providers (who may be referred to as intensivists or ICU hospitalists) are often employed by the hospital on a “shift” or “per day” basis. “On duty” hours in a critical care unit have no correlation to critical care services as paid under the Medicare Part B Fee Schedule. Critical care time is paid on a per patient/per service basis and each unit of billing must be supported by a medical record describing the specific nature and time for the service rendered.
  • CPT 99291 represents the first 30-74 minutes of critical care on a given calendar date of service. It should only be used once per calendar date per patient by the same physician of the same specialty, or a qualified NPP.  Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician and would not each report CPT 99291 on the same date of service.
  • CPT 99292 represents additional block(s) of time, of up to 30 minutes each, beyond the first 74 minutes of critical care. The service may represent aggregate time met by a single physician or members of the same group practice with the same medical specialty.
  • Critical care of less than 30 minutes total duration on a given calendar date is not reported separately using the critical care codes. This service should be reported using another appropriate E&M code such as subsequent hospital care
  • When an ED patient requires critical care services, only the critical care codes (99291-99292) may be reported as an E&M service. An ED visit code (E&M) may not also be reported by the same provider or another provider of the same group on the same day as critical care service.
  • When critical care services are provided by the same provider or group on the same date as other E&M services (office, hospital inpatient or outpatient), both the E&M and critical care service may be payable.  Providers are advised to submit documentation upon request supporting the two services.
  • Critically ill or critically injured patients may require the care of more than one physician medical specialty. Concurrent critical care services provided by each physician must be medically necessary and not provided during the same instance of time.

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Time Increments for Critical Care Codes

The following table demonstrates the correct per time increment:

Duration Code
Less than 30 minutes 99232 or 99233 or other appropriate E&M code
30-74 minutes 99291 x 1
75-104 minutes 99291 x 1 and 99292 x 1
105-134 minutes 99291 x1 and 99292 x 2
135-164 minutes 99291 x 1 and 99292 x 3
165-194 minutes 99291 x 1 and 99292 x 4
194 minutes or longer 99291-99292 as appropriate (per the above illustrations)

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CMS Examples

CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.12, has provided the following examples:

Correct Billing of Critical Care Time

  • A patient arrives in the emergency department in cardiac arrest. The emergency department physician provides 40 minutes of critical care services. A cardiologist is called to the ED and assumes responsibility for the patient, providing 35 minutes of critical care services. The patient stabilizes and is transferred to the CCU. In this instance, the ED physician provided 40 minutes of critical care services and reports only the critical care code (CPT code 99291) and not also emergency department services. The cardiologist may report the 35 minutes of critical care services (also CPT code 99291) provided in the ED. Additional critical care services by the cardiologist in the CCU may be reported on the same calendar date using 99292 or another appropriate E&M code depending on the clock time involved.

Clinical Examples of Critical Care Services 

  • Drs. Smith and Jones, pulmonary specialists, share a group practice. On Tuesday, Dr. Smith provides critical care services to Mrs. Benson who is comatose and has been in the intensive care unit for four days following a motor vehicle accident. She has multiple organ dysfunction including cerebral hematoma, flail chest and pulmonary contusion. Later on the same calendar date Dr. Jones covers for Dr. Smith and provides critical care services. Medically necessary critical care services provided at the different time periods may be reported by both Drs. Smith and Jones. Dr. Smith would report CPT code 99291 for the initial visit and Dr. Jones, as part of the same group practice would report CPT code 99292 on the same calendar date if the appropriate time requirements are met.

  • Mr. Marks, a 79-year old. comes to the emergency room with vague joint pains and lethargy. The ED physician evaluates Mr. Marks and phones his primary care physician to discuss his medical evaluation. His primary care physician visits the ER and admits Mr. Marks to the observation unit for monitoring, and diagnostic and laboratory tests. In observation Mr. Marks has a cardiac arrest. His primary care physician provides 50 minutes of critical care services. Mr. Marks’ is admitted to the intensive care unit. On the same calendar day Mr. Marks’ condition deteriorates and he requires intermittent critical care services. In this scenario the ED physician should report an emergency department visit and the primary care physician should report both an initial hospital visit and critical care services.

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Relative to Global Surgery and Other Procedures

Critical care services are usually not payable to a physician who bills a procedure code with a global surgery period on the same date of service. In unusual circumstances, when pre and postoperative care by the surgical provider is beyond customary parameters, critical care can be billed with a modifier 25. The physician’s note would be expected to fully document the separate and distinct nature of the critical care service.

When critical care is performed in the postoperative period by a provider other than the surgeon, no modifier is necessary. However, when the performing surgeon transfers patient responsibility in the global postoperative period, critical care billing by the surgeon should be billed with modifier 54 (surgical care only). When the receiving provider (e.g., an intensivist) bills critical care services, modifier 55 (postoperative management only) should be appended to the service lines. Documentation must clearly reflect the transfer of care by the operating surgeon to the other provider.

Separate payment may also be made for endotracheal intubation (CPT 31500), insertion of a flow-directed catheter (CPT 93503) and CPR (CPT 92950. Critical care should be reported with a modifier 25 in these circumstances, although time spent on the procedures cannot be counted toward critical care time. For example, a physician may spend 60 minutes at the bedside of a critically ill patient, spending 10 minutes on CPR, 20 minutes for Swan-Ganz insertion and 15 minutes on endotracheal intubation. The 45 minutes spent on these separately payable procedures does not count toward critical care time, leaving a balance of 15 minutes, which is insufficient  to bill a unit of critical care.

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Trauma and Burn Cases

When treating patients for trauma or burn injuries, preoperative and postoperative critical care may be payable along with the global surgical fee. This concept applies when the patient is critically ill and requires the treating physician’s full attention, and the critical care is unrelated to the specific injury or surgical procedure performed. In such circumstances, the medical record should reflect a situation in which there is a significant probability of imminent or life threatening deterioration in the patient’s condition, and that the critical care was unrelated to the prior surgery.

For critical care of this nature, append these modifiers as appropriate:

  • Preoperatively: Modifier 25 is appended to the critical care code(s).
  • Postoperatively: Modifier 24 is appended to the critical care code(s).

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Teaching Physician

When performing critical care, a teaching physician must meet all the above described criteria, and be present throughout the entire billed period of critical care. This time can be spent collaboratively with resident staff, but time spent by the resident in the absence of the teaching physician cannot be counted toward critical care.

Medical record documentation may reflect the combined efforts of the teaching physician and the resident in supporting critical care services. Notes by the teaching physician must clearly indicate time spent in critical care delivery, the clinical facts relative to the care, and the specific treatment and management provided by the teaching physician. An entry such as “I saw the patient and agree with the resident” is unacceptable. It is expected that the teaching physician’s note provides the details of clinical assessment, time spent and clinical management.

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Ventilator Management

Ventilator management codes (CPT Codes 94002-94004, 94660 and 94662) are not separately payable from other E&M codes, including critical care codes, on the same date of service to the same provider for the same patient. Use of modifier 25 is inappropriate in these circumstances.

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Related Content

CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 30.6.12 and 100.1.1 (1 MB)

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Critical Care Services: CPT Codes 99291-99292
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