Emergency Department (ED) critical care coding and billing can be complex for hospitals. While based on Current Procedural Terminology (CPT) guidelines, the Centers for Medicare & Medicaid Services (CMS) adds specific nuances, creating challenges for both ED providers and medical coding professionals. Understanding how time impacts different CPT codes is essential to navigate these complexities effectively.
Since January 1, 2007, hospital critical care services are reimbursed at two different levels, depending on whether trauma activation is also involved. Hospitals receive a base payment for critical care, with an additional payment available when critical care is associated with trauma activation and appropriately billed. For critical care services without trauma activation, hospitals can use CPT code 99291, which is defined as Critical Care, Evaluation and Management (E&M) of the Critically Ill or Critically Injured Patient for the First 30-74 Minutes. If the documented critical care time exceeds 74 minutes, CPT code 99292, Critical Care, should be billed for each additional 30-minute increment of critical care. Furthermore, if trauma activation occurs under the National Uniform Billing Committee (NUBC) guidelines, hospitals can also bill one unit of trauma activation code G0390, Trauma activation associated with hospital critical care services.
Time, along with the intensity and content of the service, is fundamental to critical care, often considered a high-level Evaluation and Management (E&M) service. Critical care is specifically defined as care provided to a patient with a critical illness or injury that acutely impairs one or more vital organ systems, creating a high probability of imminent or life-threatening health deterioration. The distinction between a routine E&M service and critical care hinges on this severity. According to CPT guidelines, if less than 30 minutes of critical care is provided, hospitals should bill for a standard ED visit, using a level of service consistent with their internal guidelines. Critical care necessitates high complexity decision-making to assess, manage, and support vital organ system failure, or to prevent further life-threatening decline in the patient’s condition. Examples of vital organ system failures include, but are not limited to, failures in the central nervous system, circulatory system, shock, renal, hepatic, metabolic, and respiratory systems.
The time dedicated to managing the critically ill patient is the pivotal factor. To bill for the facility component of critical care, documentation must substantiate a minimum of 30 minutes of critical care service directly provided to the patient. As outlined in Medicare Pub 100-94 MCP (Medicare Claims Processing), Transmittal 1139, issued December 22, 2006, this 30-minute minimum has consistently been a requirement under the Outpatient Prospective Payment System (OPPS) and remains in effect. CMS clarifies that under OPPS, reportable critical care time includes the time spent by physicians and/or hospital staff actively engaged in face-to-face critical care of a critically ill or injured patient.
When both physician and hospital staff, or multiple hospital staff members, are simultaneously involved in providing this face-to-face critical care, the time can only be counted once. Therefore, for accurate coding, documentation must clearly specify the start and stop times of each healthcare provider’s direct patient engagement. This detailed time tracking allows coding professionals to accurately calculate both individual and collective provider times. While time exceeding 74 minutes can be billed, it’s important to note that the 2008 Ambulatory Payment Classification (APC) payment for CPT code 99291 already includes payment for additional time billed under 99292. While separate payment for extended critical care time is not currently provided, CMS may reconsider this in the future based on critical care utilization data.
In emergency situations, critical patients often require immediate life-saving interventions, with cardiopulmonary resuscitation (CPR) being a frequent example. Critical care levels are time-dependent, but it is important to note that when CPT code 92950 for CPR is reported, the time spent performing CPR is not included in the calculation of critical care time, according to Correct Coding Initiatives (CCI) edits. CPR (CPT code 92950) is separately payable under APC 0094 as a type S procedure. Therefore, CPR and any other separately billable procedures performed by ED staff or consultants supported by ED staff can be billed by the hospital, provided that the time spent on these procedures is excluded from the time used to determine critical care service duration. Accurate and meticulous timing and documentation are therefore not just best practices, they are fundamental to compliant and optimal critical care billing.
