Critical care billing and coding, while intricate, is a cornerstone of healthcare administration, especially for professionals dedicated to intensive care units (ICUs). The demanding nature of critical care necessitates not only expert clinical skills but also a thorough understanding of the financial aspects that ensure proper reimbursement for the services provided. For clinicians in the ICU, where every minute is crucial, accurate billing reflects the intensity and complexity of their work.
Hospital systems vary significantly in their handling of critical care billing processes. Some practitioners might find themselves detached from the direct billing procedures, while others are actively involved in inputting and adjudicating billing codes. Regardless of the level of direct involvement, a foundational knowledge of critical care billing and coding is indispensable for all critical care providers. This knowledge is key to securing rightful compensation and preempting queries and clarifications related to billing discrepancies.
This article offers a comprehensive overview of critical care billing and coding, enriched with practical tips and insights to enhance your understanding and daily documentation practices. It is important to note that this guide is intended to supplement, not replace, the expertise of certified coding and billing professionals. For further in-depth resources, refer to the American College of Emergency Physicians (ACEP) critical care billing FAQ and the Society of Critical Care Medicine (SCCM), which provides valuable resources including an annual webinar on critical care billing and coding. The information presented here is specifically tailored to adult critical care patients; neonatal and pediatric critical care billing follows different protocols.
The Imperative of Documenting Medical Necessity
Variability in the interpretation and application of documentation and coding standards for critical care services is significant. This inconsistency makes it a prime area for payers to scrutinize and potentially dispute charges. Therefore, a clear and concise articulation of medical necessity in your documentation is paramount. Medical necessity, in the context of critical care, is defined by the management of one or more organ systems in failure, where the immediate and intensive intervention is essential to avert a high probability of patient deterioration or mortality.
Numerous medical conditions can warrant critical care, including but not limited to cardiac arrest, cardiogenic shock, acute liver or kidney failure, central nervous system disorders, and post-traumatic complications. Your documentation must unequivocally justify the critical nature of the patient’s condition. Steer clear of generic statements or automated phrases. Instead, provide specific details: identify the organ system(s) involved, describe the diagnostic and therapeutic interventions undertaken along with their clinical rationale, and explicitly state the potential for deterioration absent these interventions.
Documenting medical necessity is crucial for critical care billing.
While critical care is often associated with crisis scenarios, such as responding to a patient coding, the provision of care during such moments is not the sole determinant of critical care services. Critical care frequently involves the interpretation of complex physiological parameters and technological data, but again, this is not a prerequisite for billing critical care. It is crucial to understand that critical care billing is not determined by diagnosis or location alone. For instance, a patient in the ICU solely for hourly nursing monitoring may not meet the criteria for critical care. Similarly, a patient who is “critically ill but stable,” such as one on a ventilator with stable settings, may not qualify.
Conversely, critical care can be legitimately billed over consecutive days, even without changes in the patient’s status, if the underlying condition continues to demand intensive clinician attention to prevent deterioration or death. The linchpin here is meticulous documentation. It must be evident that there is active and ongoing management of vital organ systems to forestall deterioration or death, and that the provider was either at the patient’s bedside or immediately available to deliver care. Importantly, critical care is not confined to the ICU setting. Although it is most commonly delivered in the ICU, critical care services can be billed for care provided in any location, including the emergency department or, in rare instances, on a general medical floor.
Specific scenarios that do not typically meet the criteria for critical care billing include:
- Routine post-operative care in the ICU, where needs are limited to typical post-surgical management (this is considered part of the global surgical billing package).
- Care provided to patients admitted for palliative care, even if they are in the ICU.
- Patients in the ICU who do not otherwise meet the established critical care criteria (e.g., patients requiring frequent but non-critical interventions like hourly eye drops).
- Instances where the total critical care time is less than 30 minutes (as detailed below).
Critical Care: A Time-Based Coding System
A fundamental aspect of critical care billing, particularly for adult patients (defined as individuals aged 6 years and older in critical care coding), is its time-based nature. Critical care coding is based on the cumulative time spent delivering critical care to a single patient. This time can encompass various activities, including:
- Direct, face-to-face critical care at the patient’s bedside (excluding procedures that are separately billable, as outlined below).
- Discussions and consultations with the interdisciplinary care team, including specialists, advanced practice providers (APPs), and nurses, regarding the patient’s condition and care plan.
- Comprehensive review and interpretation of patient data, including laboratory results, imaging studies, and physiological monitoring data.
- Documenting notes and orders in the patient’s medical record while on the unit and immediately available for patient care.
- Engaging in discussions with family members, but specifically when the patient is unable to participate in care decisions or when obtaining a clinically pertinent history. Documenting the identity of the family member spoken with is advisable.
It is imperative to document the total critical care time in discrete minutes. Vague or blanket statements (e.g., “at least 30 minutes spent”) are insufficient for proper billing. Recognize that the time spent on critical care may fluctuate daily, so avoid simply copying forward critical care attestations from previous days.
Activities that are not included in billable critical care time are:
- Routine updates to family members that do not involve clinical decision-making.
- Time spent teaching or educating medical learners (students, residents, fellows).
- Critical care services delivered by a resident physician without the direct presence and active participation of a teaching physician.
- Time spent on patient management activities conducted off the unit, including phone consultations or remote monitoring from home.
- Procedures that are not bundled into the critical care Current Procedural Terminology (CPT) codes.
Conversely, certain procedures are considered integral to critical care and are “bundled” into the critical care billing codes. These procedures, while not separately billable, do count towards your total critical care time. Bundled procedures include the interpretation of physiological data (vital signs, pulmonary artery catheter readings, laboratory values, electrocardiograms (EKGs), chest X-rays, and other physiological parameters), placement of nasogastric (NG) or orogastric (OG) tubes, temporary transcutaneous pacing, ventilator management, and peripheral intravenous access procedures.
Procedures that can be billed separately from critical care time include endotracheal intubation, pulmonary artery catheter placement, cardiopulmonary resuscitation (CPR), central and arterial line insertions, temporary pacemaker insertion, and chest tube insertion.
Time-Based Billing Codes: CPT 99291 and 99292
Once you have accurately calculated the total critical care time, the next step is to understand how this time translates into billing codes. As previously mentioned, critical care services lasting less than 30 minutes are not billed as critical care. Instead, these services are categorized under different Evaluation and Management (E/M) codes for subsequent hospital follow-up. These codes (99231-99233) are daily bills stratified by the complexity of medical decision-making, not time.
For critical care time ranging from 30 to 74 minutes, the appropriate billing code is 99291. For extended critical care, billing is incremented in 30-minute intervals using the add-on code 99292. For example, 35 minutes of critical care is billed as 99291. A case involving 80 minutes of critical care would be billed as 99291 and 99292.
A critical update from January 2023 from Medicare stipulates that to bill 99292, the full additional 30 minutes must be completed. Specifically, for Medicare patients, a minimum of 104 (74+30) minutes of critical care is required to bill 99292 in addition to 99291. Currently, other payers may allow billing for partial increments of the 30-minute interval, but this policy is subject to change and should be monitored regularly.
Time-based coding is central to critical care billing.
Navigating Billing with Multiple Critical Care Providers
In the ICU setting, it is common for patients to receive care from a multidisciplinary team of physicians and APPs. To ensure accurate and compliant billing in these scenarios, it is important to understand the guidelines for multiple providers.
Effective 2023, Medicare guidelines specify that code 99291 can be billed only once per day per provider group, even if critical care time is not continuous. This implies that if both a critical care physician and a critical care APP from the same group provide care to the same patient on the same day, only one of them can bill 99291. To meet the time requirements for subsequent 99292 billing, the time spent by both providers is aggregated. However, providers from different groups or specialties (e.g., a pulmonologist and a cardiologist managing different organ systems) can each bill 99291 separately, provided their services are distinctly documented as non-overlapping and medically necessary. This can be complex in scenarios involving private, hospital-owned, and multidisciplinary groups. In such cases, consulting with your legal department and coding specialists is recommended to ensure compliance.
Split/Shared Billing in 2024
Further complicating billing in shared care models is the introduction of “split/shared billing” in 2024 for ICU services. In situations where both a physician and an APP from the same group or specialty jointly provide care, there must be a clear delineation of who bills for the service. This applies to both E/M services and critical care billing in inpatient settings. For critical care billing, the total cumulative time is calculated, and the provider who furnishes more than 50% of the total critical care time is designated to bill for the service, whether it is the physician or the APP. Accurate time documentation is crucial for this determination.
Key points regarding split/shared billing include:
- The physician and APP must be part of the same group and collaborate in providing care. If they are from different groups or specialties, their time is billed separately.
- To count both providers’ time, the physician and APP must see the patient at different times. Concurrent time cannot be double-counted.
- Reimbursement rates differ: Medicare reimburses 100% of the allowed amount for physician services but only 85% for APP services.
For E/M services (e.g., for ICU patients who do not meet critical care criteria), the billing responsibility rests with the provider who approves the care plan and assumes responsibility for the medical decision-making, typically the physician. In scenarios where a patient is seen separately by one physician and multiple APPs throughout the day, current guidelines lack specific direction. Proposed solutions within healthcare systems vary, including designating the provider who spent the most time or assigning billing responsibility to the physician.
Addressing Unique Billing Scenarios
Intensivists frequently manage patients in the post-operative period. While routine post-operative care in the ICU is often included in the global surgical package and does not typically qualify as critical care, this does not preclude billing critical care for post-operative patients altogether. True critical illness in the post-operative context is generally not an anticipated outcome of surgery. The critical factor is documentation: it must clearly articulate that the patient’s condition is either unrelated to the surgical procedure or, if related, necessitates critical care that is beyond the typical scope of post-surgical management. It must be evident that the intensivist’s care is a distinct service driven by medical necessity. Payers may scrutinize these charges closely, necessitating detailed documentation of medical necessity to ensure claim acceptance. It’s worth noting that certain complex cardiac surgical procedures inherently include expected critical care services within their global billing package. Given the complexity, close consultation with your coding department is advisable for intensivists working in post-operative critical care.
Further unique billing scenarios include:
- Brain Death: Critical care time cannot be billed for a patient after brain death declaration. However, all care provided up to the point of brain death determination, including brain death testing, is generally considered billable as critical care.
- Tele-ICU: The expansion of billing rules during the COVID-19 pandemic included tele-ICU services as eligible for critical care billing. This provision is currently authorized through December 2024, with the future of tele-ICU billing beyond this date remaining uncertain.
- Concurrent E/M Services: Critical care can be billed on the same day as another E/M service if the E/M service is distinctly separate and identifiable. An example is a patient seen on the medical floor in the morning who subsequently deteriorates, is transferred to the ICU, and requires resuscitation later the same day. In such cases, both an E/M and a critical care bill are appropriate. Coders will apply a billing modifier to indicate the services were unique and separate.
- Midnight Rule: When critical care spans across midnight, all continuous care is billed under the pre-midnight date of service. For instance, critical care provided from 11:30 PM on May 1, 2024, to 1:30 AM on May 2, 2024, would be billed as 120 minutes of critical care on May 1, 2024. This would be coded as 99291 for the initial 74 minutes and 99292 x 2 for non-Medicare patients (or 99292 x 1 for Medicare patients if the full 134 minutes for a second 99292 increment were not met). Subsequent, separate critical care encounters on May 2, 2024, such as from 3:00 AM to 4:00 AM, would initiate a new billing cycle starting again with 99291, billed under the date of May 2, 2024.
- ICU Transfers: Billing critical care on the day of ICU transfer is permissible but may trigger scrutiny. This scenario necessitates that the patient meets critical care criteria at some point during the day but stabilizes sufficiently for transfer later in the day. Robust documentation is crucial to support appropriate reimbursement.
- Discharge Billing: Do not overlook billing for discharge services. Discharge billing is also time-based, categorized by whether the discharge process takes less than or more than 30 minutes.
While the administrative aspects of coding and billing may not be the primary motivation for entering medicine, they are an integral part of professional practice. Ensuring accurate billing is essential for receiving due compensation for the demanding work of critical care. Effective critical care billing hinges on clear, comprehensive documentation of medical necessity and the time devoted to patient care. For complex or unique scenarios, proactive consultation with your billing and coding department is invaluable to ensure adherence to current guidelines and optimize appropriate reimbursement.
Acknowledgement: We extend our gratitude to the Society of Critical Care Medicine and Deborah Grider, CPC, for their insightful webinar, which served as a foundational resource for this article.
