Medicare Monthly Review Details

Critical Care Tip Sheet

Service and Medical Necessity

Appropriate billing for critical care services requires the documentation to support a critical illness or injury and critical intervention. 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. Just because a patient is critically ill, or is in the ICU/CCU, does not mean the care is automatically a critical care service. Refer to the chart below for examples of situations that both may and may not support the medical necessity criteria for critical care services.

Examples of Patients Whose Medical Condition May Warrant Critical Care Services Examples of Patients Whose Medical Condition May Not Warrant Critical Care Services
Patient is admitted to the ICU following abdominal aortic aneurysm resection. Two days after surgery, patient requires fluids and pressors to maintain adequate perfusion and arterial pressures and remains ventilator dependent. Daily management of a patient on chronic ventilator therapy does not meet the criteria for critical care unless the critical care is separately identifiable from the chronic long term management of the ventilator dependence.
Patient is admitted for an acute anterior wall myocardial infarction continues to have symptomatic ventricular tachycardia that is marginally responsive to antiarrhythmic therapy. Management of dialysis or care related to dialysis for a patient receiving ESRD hemodialysis does not meet the critical care unless the critical care is separately identifiable from the chronic long term management of the dialysis dependence.
Patient is three days status post mitral valve repair. Patient develops petechiae, hypotension and hypoxia requiring respiratory and circulatory support. Patient is admitted to critical care unit for close nursing observation and/or frequent monitoring of vital signs (e.g., drug toxicity or overdose).
Patient is admitted for right lower lobe pneumococcal pneumonia with a history of COPD becomes hypoxic and hypotensive two days after admission. Patient admitted to critical care unit because hospital rules require certain treatments (e.g., insulin infusions) to be administered in the critical care unit.
Patient is in a critical, intensive, or specialized care unit who are clinically stable and responding favorably to established interventions.
Patient admitted to critical care unit because no other hospital beds were available.

The Following CMS Billing Consideration Guidelines Apply

  • When an emergency department (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.

Provider Time Assessment and Documentation

Critical care services are represented by time-based codes. 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. Critical care service time must be exclusive to the patient.

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 of different specialties, each whom must carefully document his/her own role in the care and time spent.

The following chart displays examples when it is appropriate for a physician or NPP to bill using critical care time-based codes while providing critical care to a patient:

Critical Care and Time Spent Other Code
Time documented as minutes (e.g., 70 minutes) or clock time (e.g., 8:30–9:45 a.m.) Subjective statements (e.g., ‘had lengthy discussion with family’ or ‘spent a long time with patient and family’).
Time spent exclusively with patient. Time spent in the ICU/CCU but physician performs services for multiple patients.
Face-to-face discussion with family to obtain patient history or determine treatment decisions when patient is unable. Time spent providing routine daily updates to family or healthcare proxies.
Time spent reviewing diagnostic and laboratory findings and discussing patient’s management with colleagues while in the ICU/CCU. Time spent off the ICU/CCU and/or teaching sessions with hospital residents often performed during round.

The Following CMS Billing Consideration 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 is providing care to a critically ill patient.
  • 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 group member.
  • 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, including NPP members of the group.
  • 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.

Time Increments for Critical Care Codes

The following chart 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 x 1 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)

Bundled Versus 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 therefore, should not be billed separately from the critical care codes:

Procedure CPT Code
The interpretation of cardiac output measurements 93598
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)
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.