Critical Care Policy Clarification

The CMS implemented the new policy for critical care services as published in the Centers for Medicare & Medicaid Services Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.12.1 and defines critical care as per CPT guidelines, along with the CPT listing of bundled services. Critical care is the direct delivery by a physician(s) or other QHP of medical care for a critically ill/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.  It involves high complexity decision-making to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition. 

Critical care is not billable simply because a patient is in an intensive care, or progressive care unit. An acute impairment, an incident that leads to the need for critical care, or life-saving procedure(s) would apply to critical care services.

All other types of services that are provided to patient’s that are in intensive care would be billed under the procedure codes relevant to the service(s) provided. 

The new policy issued by CMS also allows critical care to be performed on a single date of service by one physician/practitioner, or by a combination of providers in a group, including both physicians and nonphysician practitioners. The total time spent providing critical care services by a single, or by multiple practitioners is used to determine the billing for those services. The practitioner who provides the substantive portion, greater than 50% of the time, would bill for the critical care service with modifier FS. These are split/shared critical care services and are explained throughout Section 30.6.12. Policy also clarifies that practitioners must document in the medical record the total time spent on critical care services by each contributing practitioner, clearly explaining individual contributions to care.

Guidelines for billing split/shared critical care services represented by CPT 99292 are found in the CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.12.1, and are the same as those applied to prolonged service codes for other types of E/M services. This means that the full timeframe for each code must be met in order to add it to the claim. In critical care, after 75 minutes of cumulative time has been spent, meeting the requirement for CPT 99291, the billing practitioner may report one or more units of CPT 99292 only when another full 30 minutes of time has been spent. Each 30-minute segment beyond that would support an additional unit of CPT 99292. 

This table represents the time based requirement and billing parameters. If 90 minutes of critical care is provided it is not appropriate to bill 99292 for an extra unit of service.

Total Duration of Critical Care Time	CPT Code(s)
Less than 30 minutes	Report using appropriate E/M code, not 99291.
30-74 minutes	99291
104 minutes	99291 and 99292
134 minutes	99291 and 99292 x 2
164 minutes	99291 and 99292 x 3
194 minutes	99291 and 99292 x 4

 

Reviewed 10/10/2023