Critical Care

Critical Care Services: CPT Codes 99291-99292

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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.

Critical care services may be performed on a split/shared basis (as of 1/1/2022) by physician and NPP members of a group. The split/shared rule for critical care allows for billing based on cumulative time spent and documented by both practitioners; the service is billed by the physician or NPP who spent and documented the greater component of the total service time.

Individual units of critical care time can be reported by separate 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.

After the criteria of 74 minutes has been met for the 99291 base code, subsequent units of add-on code 99292 may be billed for each additional 30 minutes of critical care.

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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. Medically necessary critical care may occur in multiple, sequential episodes performed by same-specialty providers and their group member NPPs. Non-continuous time for critical care services by same specialty or split/shared services is aggregated for a 24-hour period to support correct coding of 99291 and, when applicable, 99292.

In addition, simultaneous episodes of critical care by physician providers of different specialties may be medically necessary; in this scenario, each provider must document his/her own role in the care and the time spent. 

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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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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 or NPP may bill for critical care services during any one single period of time, even if more than one physician or NPP 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 each critical care time block of 30 minutes beyond the first 74 minutes of critical care.
  • 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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Relative to Global Surgery and Other Procedures

Critical care services may be payable to a physician who bills a procedure code with a global surgery period when the critical care service is unrelated to the surgery. In this circumstance, critical care may be billed with modifiers 24 and FT. Modifier FT is effective as of 1/1/2022 and mandatory on these claims as of 3/1/2022. 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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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.

Revised 4/26/2022