Critical care coding is a vital aspect of medical billing, especially when dealing with patients facing life-threatening conditions. Understanding the nuances of critical care services, particularly CPT codes 99291 and 99292, is crucial for healthcare providers and coders alike. This guide addresses frequently asked questions to clarify Critical Care Coding Scenarios and ensure accurate billing practices.
1. What Exactly Constitutes Critical Care Service According to CPT (Codes 99291 and 99292)?
The Current Procedural Terminology (CPT) defines a critical illness or injury as one that acutely impairs one or more vital organ systems. This impairment creates a high probability of imminent or life-threatening deterioration in the patient’s condition.
Critical care services, in turn, are defined as the direct medical care delivered by a physician or other qualified healthcare professional (QHP) to a critically ill or injured patient. It’s characterized by high-complexity decision-making to assess, manipulate, and support vital organ system failure, or to prevent further life-threatening decline. Examples of vital organ system failures include, but are not limited to:
- Central nervous system failure
- Circulatory failure
- Shock
- Renal failure
- Hepatic failure
- Metabolic failure
- Respiratory failure
2. How Does Medicare’s Definition of Critical Care Compare to CPT’s?
For the most part, Medicare aligns with CPT in its definition of critical care and the services included when reporting critical care time. Both entities agree on what constitutes critical care and what activities are countable towards critical care time. However, a key difference emerges in how critical care time beyond the initial period is reported, particularly concerning the use of code 99292. This discrepancy in reporting extended critical care time is detailed further in FAQ #5.
3. How is Physician or QHP Time Calculated for Critical Care Codes?
Determining the correct critical care code hinges on accurately measuring the time a physician or QHP spends delivering these services. The duration is based on the total time documented by the physician/QHP spent evaluating, managing, and providing care to the critically ill patient, including the time spent on documenting these activities. Crucially, during this entire accrued time, the physician/QHP must be fully focused on that specific patient. This time can be spent at the patient’s bedside or elsewhere on the unit, as long as the physician remains immediately available to the patient.
Time spent on critical care services encompasses work directly related to the individual patient’s care, whether at the bedside or in other locations. Examples include:
- Time at the bedside providing direct patient care.
- Reviewing test results and formulating treatment plans.
- Discussing the patient’s case with other healthcare staff.
- Documenting the medical record.
- Communicating with family members (or surrogate decision-makers) to discuss specific treatment issues when the patient cannot participate due to their condition.
Activities that do not directly contribute to the treatment of the critical patient, such as general administrative tasks or breaks, cannot be counted towards critical care time. Furthermore, the “critical care accrual clock” is paused when separately reportable procedures or services are performed; this time should not be included in the total critical care time.
Codes 99291 and 99292 report the total accumulated critical care service time provided on a single date, even if that time is not continuous. Non-continuous critical care time can be aggregated for a single date. CPT code 99291 is used only once per date when a minimum of 30 minutes of critical care services are provided. Critical care time less than 30 minutes is not reported using critical care codes; instead, the appropriate Evaluation and Management (E/M) code should be used.
It’s important to note that only time-based critical care codes (99291 and 99292) are appropriate for services in the Emergency Department (ED). Neonatal (99468-99469) and pediatric (99471, 99472, 99475, and 99476) critical care codes are exclusively for inpatient settings.
4. How is Combined Physician/QHP Time Counted for Code Selection?
Codes 99291 and 99292 are used to report the cumulative critical care time delivered by both a physician and a QHP, even if the time spent is non-continuous throughout the day. Time spent separately by a physician and a QHP on the same patient can be combined to reach the time thresholds for coding. However, it’s crucial to avoid double-counting time.
According to both CMS and, as of January 1, 2024, CPT guidelines, the provider who furnishes the majority of the critical care time is the one who should report the critical care code. This ensures that only one provider bills for the combined critical care time.
5. Are CPT and CMS Reporting Standards for Critical Care Time Consistent?
No, this is a significant point of divergence between CPT and CMS guidelines. For CPT coding, code 99291 is used to report the initial 30–74 minutes of critical care provided on a given date. It is used only once per date. Code 99292 comes into play when the total critical care time extends beyond the initial 74 minutes covered by 99291. If the total critical care time falls within the 75-104 minute range, 99292 is reported in addition to 99291. For each subsequent 30-minute block of time reached, an additional unit of 99292 is reported.
However, CMS has a different approach. Starting in Calendar Year 2023, CMS stipulates that 99292 can only be reported when a full additional 30 minutes of critical care time has been provided beyond the initial 74 minutes (meaning a total of 104 minutes or more). This means CMS requires a full 30-minute increment for each unit of 99292, whereas CPT allows for reporting 99292 even for time slightly exceeding the initial 74 minutes.
Here’s a table summarizing the differences:
| CPT | CMS | |
|---|---|---|
| Less than 30 minutes | Appropriate E/M codes | Less than 30 minutes |
| 30–74 minutes | 99291 X 1 | 30–103 minutes |
| 75–104 minutes | 99291 X 1, 99292 X1 | 104 minutes |
| 105–134 minutes | 99291 X 1, 99292 X2 | 134 minutes |
| 135–164 minutes | 99291 X 1, 99292 X 3 | 164 minutes |
| 165 minutes and longer | 99291 and 99292 as appropriate | 165 minutes and longer |
6. What Happens When Critical Care Spans Across Calendar Days?
Critical care codes (99291, 99292) are designed for services provided on a single calendar date. However, critical care scenarios can extend past midnight. CPT and CMS coding principles dictate that when a continuous, time-dependent service crosses over midnight, the entire time should be attributed to and reported on the pre-midnight date. Conversely, if the service is interrupted and becomes non-continuous, a new initial service may be necessary on the post-midnight date.
Consider these critical care coding scenarios:
Scenario 1: A patient arrives in the ED at 11:35 PM on Day 1. Critical care services begin immediately and continue uninterrupted until 12:15 AM on Day 2. No further critical care services are provided on Day 2. How should this be coded?
Answer: Since 40 minutes of continuous critical care were provided across midnight, critical care code 99291 should be reported for Day 1. The entire duration is attributed to the service date on Day 1.
Scenario 2: A patient presents to the ED at 11:35 PM on Day 1. Critical care is initiated and continues until 12:15 AM on Day 2, at which point it is interrupted. Critical care services are resumed at 1:30 AM on Day 2, with an additional 65 minutes of care provided. How should this scenario be coded?
Answer: Critical care 99291 should be reported for Day 1, covering the initial 40 minutes. A second 99291 can be reported for Day 2, representing the 65 minutes of critical care provided after the service was re-initiated. The interruption of service creates two separate critical care service periods across the two days.
In such scenarios, clear documentation is essential to demonstrate the circumstances and justify the coding.
7. What Documentation is Essential for Using Critical Care Codes 99291 and 99292?
To appropriately use critical care service codes, both the patient’s condition and the treatment provided must meet the established criteria. The physician/QHP’s medical record documentation must provide substantive information to support the use of these codes. Specifically, the documentation must clearly demonstrate:
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The patient’s condition meets the definition of a critical illness or injury. The documentation should describe the acute impairment of one or more vital organ systems and the high probability of imminent or life-threatening deterioration.
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The total critical care time delivered must be documented and must be a minimum of 30 minutes. This documented time should be exclusive of any separately reportable procedure time. The documentation should detail the time spent in activities directly related to the patient’s critical care as outlined in FAQ #3.
8. What are the Documentation Requirements for Teaching Physicians Supervising Residents in Critical Care?
Specific rules apply to critical care services provided in a teaching setting under Medicare’s Teaching Physician Criteria. Time spent solely by a resident performing critical care activities without the direct involvement of the teaching physician cannot be counted towards critical care time. Only the time the teaching physician personally spends providing critical care activities can be included.
While a teaching physician can reference a resident’s documentation for details on patient history, physical findings, and medical assessments, the teaching physician must independently document certain key elements. This documentation must include:
- A statement of the total time the teaching physician personally spent providing critical care.
- Confirmation that the patient was critically ill when the teaching physician evaluated them.
- A clear description of what made the patient critically ill (the specific critical condition).
- The nature of the treatment and management provided by the teaching physician.
CMS provides an example of acceptable documentation: “Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident’s documentation, and I agree with the resident’s assessment and plan of care.”
For more detailed information, refer to CMS Transmittal 1548.
9. Can Critical Care Codes Be Reported with Other E/M Codes for Non-Medicare Patients on the Same Day?
Yes, CPT guidelines allow for reporting both an Evaluation and Management (E/M) service and a critical care service on the same calendar day for non-Medicare patients. CPT does not differentiate based on the site of service or the order in which services are provided.
However, some payers may require the use of modifier -25 appended to the non-critical care E/M service to indicate that it was a separately identifiable service (see FAQ #10). Providers should verify specific payer requirements.
10. What About Reporting Critical Care Codes with Other E/M Codes for Medicare Patients on the Same Day?
CMS policy regarding reporting critical care and other E/M services on the same day for Medicare patients has evolved. Prior to 2022, CMS generally disallowed reporting both an ED E/M code (9928x series) and critical care on the same day.
Currently, CMS policy permits reporting critical care services provided after an Emergency Department E/M service is completed, but not the reverse. This means if a Medicare patient presents to the ED, receives an initial ED evaluation and workup (coded with 99281-99285), and subsequently requires critical care on the same date, the ED physician/QHP can report both the 9928x service and critical care.
However, if a patient receives critical care services immediately upon arrival in the ED and then later receives additional ED services after stabilization, an ED E/M code may not be reported by the same physician/QHP in the same group for the same encounter. In this scenario, only either the ED E/M service or the critical care service should be reported—not both.
CMS mandates the use of modifier -25 when both 9928x codes and critical care services are provided on the same date by the same group to signify a separately identifiable E/M service.
11. Which Procedure Codes are Bundled into Critical Care Codes According to CPT?
When critical care is reported, certain services are considered inherent components of critical care and are “bundled” into the critical care “clock time.” When performed by the same physician(s) providing critical care during the critical care period, these services should not be reported separately. These bundled services include:
- Interpretation of cardiac output measurements (CPT 93598)
- Pulse oximetry (CPT 94760, 94761, 94762)
- Chest x-rays, professional component (CPT 71045, 71046)
- Blood gases, and the collection and interpretation of physiologic data (e.g., ECGs, blood pressures, hematologic data)
- Gastric intubation (CPT 43752, 43753)
- Transcutaneous pacing (CPT 92953)
- Ventilator management (CPT 94002-94004, 94660, 94662)
- Vascular access procedures (CPT 36000, 36410, 36415, 36591, 36600)
Any services performed that are not on this bundled list may be reported separately in addition to critical care codes (see FAQ #12).
12. Does Medicare’s Bundling of Procedures with Critical Care Differ from CPT?
Medicare’s bundling policy for procedures within critical care services is consistent with CPT guidelines. Medicare also bundles the same set of services (listed in FAQ #11) into critical care when performed by the same physician(s) reporting critical care.
Since 2022, CMS requires modifier “FT” to be appended to procedures with a global period when they are bundled into critical care. Additionally, modifier -25 is required for a separately identifiable E/M service that is unrelated to the bundled procedure but performed on the same day as critical care.
13. What are Examples of Procedures that Can Be Billed Separately from Critical Care?
When performing procedures that are not bundled into critical care, the “critical care accrual clock” pauses. The time spent performing these separately billable procedures should not be included in the total critical care time reported. Examples of common procedures that may be reported separately for a critically ill or injured patient include (but are not limited to):
- Cardiopulmonary Resuscitation (CPR) (92950) (only the time spent actively performing CPR is excluded from critical care time)
- Endotracheal intubation (31500)
- Central line placement (36555, 36556)
- Intraosseous placement (36680)
- Tube thoracostomy (32551)
- Temporary transvenous pacemaker (33210)
- Electrocardiogram (ECG) – routine ECG with at least 12 leads; interpretation and report only (93010)
- Elective electrical cardioversion (92960)
This list is not exhaustive but provides examples of procedures commonly performed in critical care scenarios that may be billed separately when medically necessary and appropriately documented.
14. When is Modifier -25 Appropriately Used with Critical Care and Separately Billable Services?
CPT guidelines do not mandate the use of modifier -25 when billing for critical care services and separately billable (non-bundled) procedures. However, some payers, including Medicare, may require modifier -25 in specific situations to ensure payment for both critical care and a separately performed procedure on the same day.
For payers requiring modifier -25, it signifies that the critical care service is “a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative care associated with the procedure that was performed.”
For instance, when procedures like endotracheal intubation (CPT code 31500) and CPR (CPT code 92950) are performed on a critically ill patient, separate payment may be made for critical care in addition to these services if the critical care was a significant, separately identifiable service, and it is reported with modifier -25. Again, the time spent providing these unbundled services is excluded from the calculation of critical care time.
15. Can CPR and Critical Care Be Reported for the Same Patient Encounter?
Yes, both CPR (CPT 92950) and critical care codes can be reported for the same patient encounter, provided that the specific requirements for each service are met and clearly documented in the medical record. Both CPT and Medicare concur on this point.
CPR (CPT 92950) is classified as a non-E/M service encompassing activities such as performing or supervising chest compressions, ensuring adequate patient ventilation (e.g., using a bag-valve-mask), and related resuscitative efforts. As it is a separately reportable service alongside critical care, the time spent providing CPR itself cannot be included when calculating the total critical care time.
16. What are the Rules for Split/Shared Critical Care Services Involving Physicians and QHPs (PAs, NPs) Under Medicare?
In 2022, CMS updated its guidance on split/shared critical care visits involving Physician Assistants (PAs), Nurse Practitioners (NPs), and physicians. The updated rules allow for the combination of total critical care time spent by both the physician and the QHP. To accurately reflect patient acuity and the care delivered, it’s recommended that both physicians and QHPs document their individual critical care time, even if it is less than 30 minutes for each provider individually.
For split or shared visits, both CPT and Medicare guidelines specify that the provider who furnishes the majority of the total combined critical care time is the provider who should report the critical care codes. This ensures appropriate billing and reflects the primary provider of critical care in shared service scenarios.
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