CPT 99291 - 99292 - Critical care services code

Procedure Description

• Procedure  Code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes)

• Procedure  Code 99292 (each additional 30 minutes, list separately in addition to code for primary service)  Average fee payment $300


Medicare Billing Guidelines

Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292) 

Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292)),replacing all previous critical care payment policy language in the section and adding general Medicare evaluation and management (E/M) payment policies that impact payment for critical care services.


Use of Critical Care Codes (CPT codes 99291-99292) 

When all these criteria are met, Medicare contractors (carriers and A/B MACs) will pay for critical care and critical care services that you report with CPT codes 99291 and 99292 .

Physicians assigned to a critical care unit (e.g., hospitalist, intensivist etc.) may not report critical care for patients based on a ‘per shift” basis. You should use CPT code 99291 (evaluation and management of the critically ill or critically injured patient, first 30-74 minutes) to report the first 30-74 minutes of critical care on a given calendar date of service. You can only use this code once per calendar date to bill for care provided for a particular patient by the same physician or physician group of the same specialty.

Clinical Example of Correct Billing of Time: 

A patient arrives in the emergency department (ED) in cardiac arrest. The emergency department physician provides 40 minutes of critical care services. A cardiologist is called to the ED and assumes responsibility for the patient, providing 35 minutes of critical care services. The patient stabilizes and is transferred to the CCU. In this instance, the ED physician provided 40 minutes of critical care services and reports only the critical care code (CPT code 99291) and not also codes for emergency department services. Using CPT code 99291, the cardiologist may also report the 35 minutes of critical care services provided in the ED. Additional critical care services by the cardiologist in the CCU (on the samecalendar date) using 99292 or another appropriate E/M code depending on the clock time involved.

The initial critical care time (billed as CPT code 99291) must be met by a single physician or qualified NPP. This may be performed in a single period of time or be cumulative by the same physician on the same calendar date. A history or physical examination performed by one group partner for another group partner in order for the second group partner to make a medical decision would not represent critical care services.

Physicians in the same group practice who have the same specialty may not each report CPT initial critical care code 99291 for critical care services to the same patient on the same calendar date.

• Physicians in the same group practice, with different specialties, who provide critical care to a critically ill or critically injured patient may not always each report the initial critical care code (CPT 99291) on the  same date. When these physicians are providing care that is uniqueto his/her individual medical specialty, and are managing at least one of the patient’s critical illness(es) or critical injury(ies); then the initial critical care service may be payable to each. However, if a physician (or qualified NPP) within a group provides “staff coverage” or “followup” for each other after another group physician provided the first hour of critical care services on that same calendar date but has left the case; the second group physician (or qualified NPP) should report the CPT critical care add-on code 99292, or another appropriate E/M code.


Can a provider submit a hospital inpatient or office/outpatient evaluation on the same calendar date as a critical service?

Answer:
If a hospital inpatient or office/outpatient evaluation and management service (E/M) is furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical Care Services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service.


Q1. Please explain how critical care is not billable in a moment of crisis. If care is delivered in a moment of crisis or emergently, is this not considered critical care?

Critical care is defined as the direct delivery by a physician(s) medical care for a critically ill or critically injured patient. A 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.

and

Critical care services encompass both treatment of "vital organ failure" and "prevention of further life threatening deterioration of the patient's condition." Therefore, although critical care may be delivered in a moment of crisis or upon being called to the patient's bedside emergently, this is not a requirement for providing critical care service. The treatment and management of the patient's condition, while not necessarily emergent, shall be required, based on the threat of imminent deterioration (i.e., the patient shall be critically ill or injured at the time of the physician's visit).

As indicated, if critical care is given in a moment of crisis, or if a provider is called to the patient's bedside based on a potential that the patient's health is in serious jeopardy, or to avoid serious impairment or dysfunction, these points do not meet the requirement for providing critical care: "vital organ failure" and "prevention of further life threatening deterioration" are not universally evident in these scenarios. Care provided during a "moment of crisis" or "upon being called to the patient's bedside emergently" may result in critical care being provided - for each case, documentation should indicate the medical necessity of the level/type of treatment.

Additionally, 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.

Q2. In cases where both the physician and non-physician practitioner (NPP) provided critical care on the same day, regardless of who saw the patient first (physician/NPP), could the physician report 99291 (if the time was met) or would 99291 need to be reported under who saw them first?

A. In regard to critical care services, the CMS IOM does not make distinction regarding who sees a patient first. A split/shared E/M service performed by a physician and a qualified NPP of the same group practice (or employed by the same employer) cannot be reported as a critical care service. Critical care services are reflective of the care and management of a critically ill or critically injured patient by an individual physician or qualified non-physician practitioner for the specified reportable period of time and shall not be representative of a combined service between a physician and a qualified NPP.

Medicare will pay for services reported with Current Procedural Terminology® (CPT®) codes 99291 and 99292 when all the criteria for critical care and critical care services are met. When CPT® code time requirements for both 99291/99292 and critical care criteria are met for a medically necessary visit by a qualified NPP, the service shall be billed using the appropriate individual National Provider Identifier (NPI) number. Medically necessary visit(s) that do not meet these requirements shall be reported as subsequent hospital care services.

Medically necessary critical care services provided on the same calendar date to the same patient by physicians representing different medical specialties that are not duplicative services are payable. The medical specialists may be from the same group practice or from different group practices.

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. Medical record documentation must support the medical necessity of critical care services provided by each physician (or qualified NPP).


Q3. Can you clarify the circumstances when an E/M service can be billed on the same day as critical care?

A. When critical care services are required upon the patient's presentation to the hospital emergency department, only critical care codes 99291-99292 may be reported. An emergency department visit code may not also be reported.

When critical care services are provided on a date where an inpatient hospital or office/outpatient E/M service was furnished earlier on the same date at which time the patient did not require critical care, both the critical care and the previous E/M service may be paid. Hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician to the same patient.

Physicians are advised to submit documentation to support a claim when critical care is additionally reported on the same calendar date as when other evaluation and management services are provided to a patient by the same physician or physicians of the same specialty in a group practice.


Q6. If a physician provides/documents a critical care service (99291) in the morning, and later in the day sees the patient again, documenting a 99292 service, would both services be reimbursed?

A. Critical care is a time-based service, and for each date and encounter entry, the physician's progress note(s) shall document the total time that critical care services were provided.

The CPT® critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous. Non-continuous time for medically necessary critical care services may be aggregated. Reporting CPT® code 99291 is a prerequisite to reporting CPT® code 99292, which is an add-on code


Critical Care Services and Physician Time

Critical care is a time- based service, and for each date and encounter entry, the physician's progress note(s) shall document the total time that critical care services were provided. More than one physician can provide critical care at another time and be paid if the service meets critical care, is medically necessary and is not duplicative care.

Concurrent care by more than one physician (generally representing different physician specialties) is payable if these requirements are met.

The CPT critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous.

Non-continuous time for medically necessary critical care services may be aggregated. Reporting CPT code 99291 is a prerequisite to reporting CPT code 99292. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician



Critical Care Services


Hospitals should separately report all HCPCS codes in accordance with correct coding principles, Procedure  code descriptions, and any additional CMS guidance, when available. Specifically with respect to Procedure  code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), hospitals must follow the Procedure  instructions related to reporting that Procedure  code. Prior to January 1, 2011, any services that Procedure  indicates are included in the reporting of Procedure  code 99291 (including those services that would otherwise be reported by and paid to hospitals using any of the Procedure  codes specified by Procedure ) should not be billed separately by the hospital. Instead, hospitals should report charges for any services provided as part of the critical care services. In establishing payment rates for critical care services, and other services, CMS packages the costs of certain items and services separately reported by HCPCS codes into payment for critical care services and other services, according to the standard OPPS methodology for packaging costs.

Beginning January 1, 2011, in accordance with revised Procedure  guidance, hospitals that report in accordance with the Procedure  guidelines will begin reporting all of the ancillary services and their associated charges separately when they are provided in conjunction with critical care. CMS will continue to recognize the existing Procedure  codes for critical care services and will establish payment rates based on historical data, into which the cost of the ancillary services is intrinsically packaged. The I/OCE conditionally packages payment for the ancillary services that are reported on the same date of service as critical care services in order to avoid overpayment. The payment status of the ancillary services does not change when they are not provided in conjunction with critical care services. Hospitals may use HCPCS modifier -59 to indicate when an ancillary procedure or service is distinct or independent from critical care when performed on the same day but in a different encounter.


Beginning January 1, 2007, critical care services will be paid at two levels, depending on the presence or absence of trauma activation. Providers will receive one payment rate for critical care without trauma activation and will receive additional payment when critical care is associated with trauma activation.

To determine whether trauma activation occurs, follow the National Uniform Billing Committee (NUBC) guidelines in the Claims Processing Manual, Pub 100-04, Chapter 25, §75.4 related to the reporting of the trauma revenue codes in the 68x series. The revenue code series 68x can be used only by trauma centers/hospitals as licensed or designated by the state or local government authority authorized to do so, or as verified by the American College of Surgeons. Different subcategory revenue codes are reported by designated Level 1-4 hospital trauma centers. Only patients for whom there has been prehospital notification based on triage information from prehospital caregivers, who meet either local, state or American College of Surgeons field triage criteria, or are delivered by inter-hospital transfers, and are given the appropriate team response can be billed a trauma activation charge.

When critical care services are provided without trauma activation, the hospital may bill Procedure  code 99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (and 99292, if appropriate). If trauma activation occurs under the circumstances described by the NUBC guidelines that would permit reporting a charge under 68x, the hospital may also bill one unit of code G0390, which describes trauma activation associated with hospital critical care services. Revenue code 68x must be reported on the same date of service. The OCE will edit to ensure that G0390 appears with revenue code 68x on the same date of service and that only one unit of G0390 is billed. CMS believes that trauma activation is a one-time occurrence in association with critical care services, and therefore, CMS will only pay for one unit of G0390 per day.

The Procedure  code 99291 is defined by Procedure  as the first 30-74 minutes of critical care. This 30 minute minimum has always applied under the OPPS. The Procedure  code 99292, Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes, remains a packaged service under the OPPS, so that hospitals do not have the ongoing administrative burden of reporting precisely the time for each critical service provided. As the Procedure  guidelines indicate, hospitals that provide less than 30 minutes of critical care should bill for a visit, typically an emergency department visit, at a level consistent with their own internal guidelines.

Under the OPPS, the time that can be reported as critical care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or critically injured patient. If the physician and hospital staff or multiple hospital staff members are simultaneously engaged in this active face-to-face care, the time involved can only be counted once.

• Beginning in CY 2007 hospitals may continue to report a charge with RC 68x without any HCPCS code when trauma team activation occurs. In order to receive additional payment when critical care services are associated with trauma activation, the hospital must report G0390 on the same date of service as RC 68x, in addition to Procedure  code 99291 (or 99292, if appropriate.)

• Beginning in CY 2007 hospitals should continue to report 99291 (and 99292 as appropriate) for critical care services furnished without trauma team activation. Procedure  99291 maps to APC 0617 (Critical Care). (Procedure  99292 is packaged and not paid separately, but should be reported if provided.)

1. Off the Unit/Floor

Time spent in activities (excluding those identified previously in Section C) that occur outside of the unit or off the floor (i.e., telephone calls, whether taken at home, in the office, or elsewhere in the hospital) may not be reported as critical care because the physician is not immediately available to the patient. This time is regarded as pre- and post service work bundled in evaluation and management services.

2. Split/Shared Service

A split/shared E/M service performed by a physician and a qualified NPP of the same group practice (or employed by the same employer) cannot be reported as a critical care service. Critical care services are reflective of the care and management of a critically ill or critically injured patient by an individual physician or qualified non-physician practitioner for the specified reportable period of time.

Unlike other E/M services where a split/shared service is allowed the critical care service reported shall reflect the evaluation, treatment and management of a patient by an individual physician or qualified non physician practitioner and shall not be representative of a combined service
between a physician and a qualified NPP.

When CPT code time requirements for both 99291 and 99292 and critical care criteria are met for a medically necessary visit by a qualified NPP the service shall be billed using the appropriate individual NPI number. Medically necessary visit(s) that do not meet these requirements shall be
reported as subsequent hospital care services.

3. Unbundled Procedures

Time involved performing procedures that are not bundled into critical care (i.e., billed and paid separately) may not be included and counted toward critical care time. The physician's progress note(s) in the medical record should document that time involved in the performance of separately
billable procedures was not counted toward critical care time.

4. Family Counseling/Discussions

Critical care CPT codes 99291 and 99292 include pre and post service work. Routine daily updates or reports to family members and or surrogates are considered part of this service. However, time involved with family members or other surrogate decision makers, whether to obtain a history or
to discuss treatment options (as described in CPT), may be counted toward critical care time when these specific criteria are met:

a) The patient is unable or incompetent to participate in giving a history and/or making treatment decisions, and

b) The discussion is necessary for determining treatment decisions.

For family discussions, the physician should document:

a. The patient is unable or incompetent to participate in giving history and/or making treatment decisions
b. The necessity to have the discussion (e.g., "no other source was available to obtain a history" or "because the patient was deteriorating so rapidly I needed to immediately discuss treatment
options with the family",

c. Medically necessary treatment decisions for which the discussion was needed, and

d. A summary in the medical record that supports the medical necessity of the discussion
All other family discussions, no matter how lengthy, may not be additionally counted towards critical care. Telephone calls to family members and or surrogate decision-makers may be counted towards critical care time, but only if they meet the same criteria as described in the aforementioned paragraph.

5. Inappropriate Use of Time for Payment of Critical Care Services.

Time involved in activities that do not directly contribute to the treatment of the critically ill or injured patient may not be counted towards the critical care time, even when they are performed in the critical care unit at a patient's bedside (e.g., review of literature, and teaching sessions with
physician residents whether conducted on hospital rounds or in other venues).


Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292)

Contractor shall instruct physicians and qualified NPPs that when critical care services are performed in the hospital emergency department (ED) they may report only critical care code 99291 and 99292 and not ED codes

Contractor shall instruct physicians and qualified NPPs that the first hour of critical care identified by Procedure  code 99291 shall be met by a single physician or qualified NPP

Contractor shall instruct physicians and qualified NPPs that physicians in the same group practice who have the same specialty shall not each report an initial critical care code 99291 on a given date

Contractor shall instruct physicians and qualified NPPs that a physician or qualified NPP who is providing “staffcoverage” or “follow-up” for a physician who provided the first hour of critical care and has left for the day shall report Procedure  code 99292 for critical care services and not Procedure  code 99291

Contractor shall instruct physicians and qualified NPPs that for services referenced in BR 5993.24 to be paid modifier -25 must be appended to the critical care code(s) 99291 and 99292 on the same date of the procedure by the same physician

Contractor shall instruct physicians and qualified NPPs that for services identified in BR 5993.25 to be paid, modifier -24 (unrelated E/M service during a postoperative period) must be appended to the critical care code(s) 99291 and 99292 on the given date of the procedure by the same physician


Definitions: 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes 99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service)


Policy: The terminology for critical care codes 99291 and 99292 specifies that the codes and number of services billed for these services rendered by a physician must be reported using the actual amount of time spent with the patient. Code 99292 is used to report each additional 30 minutes beyond the first 74 minutes. It also may be used to report the final 15-30 minutes of critical care on a given date.

The following services are considered part of critical care (99291,99292) when performed on the same day, by the same physician providing critical care: the interpretation of cardiac output measurements (93561, 93562), chest X-rays (71010, 71015, 71020), pulse oximetry (94760, 94761, 94762), blood gases, and information data stored in computers (e.g., ECGs, blood pressures, hematologic data (99090); gastric intubation (43752, 43753); temporary transcutaneous pacing (92953); ventilatory management (94002-94004, 94660, 94662); and vascular access procedures (36000, 36410, 36415, 36591, 36600).

When any of these services are reported in addition to critical care, payment for the services is included in the payment for the critical care codes 99291 and 99292. Any services performed that are not listed should be reported separately.

Critical Care billing modifiers

Critical care services furnished during a global surgical period for a seriously injured or burned patient are not considered related to a surgical procedure and may be paid separately under the following circumstances.


Pre-operative and post-operative critical care may be paid in addition to a global fee if:

• The patient is critically ill and requires the constant attendance of the physician; and

• The critical care is above and beyond, and, in most instances, unrelated to the specific anatomic injury or general surgical procedure performed.

Such patients are potentially unstable or have conditions that could pose a significant threat to life or risk of prolonged impairment.

In order for these services to be paid, two reporting requirements must be met:

• CPT codes 99291/99292 and modifier “-25” for pre-operative care or “-24” for post-operative care must be used; and

• Documentation that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed must be submitted. An ICD-10 code for a disease or separate injury which clearly indicates that the critical care was unrelated to the surgery is acceptable documentation.

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