CRITICAL CARE SERVICES Procedure CODES 99291-99292

Critical care services

Critically ill is defined as a critical illness or injury that acutely impairs one or more vital organ systems indicating a high probability of imminent or life threatening deterioration in the patient’s condition.

The following procedures/services are included in reporting critical care when performed during the critical period and, therefore, should not be coded separately. Please see Proceure  for specific code definitions. 36000, 36410, 36415, 36540, 36600, 43752, 71010, 71015, 71020, 91105, 92953, 93561, 93562, 94002, 94003, 94004, 94660, 94662, 94760, 94761, 94762, 99090.



Provider billing guidelines

Code           Description          Comments

94760, 94761
Noninvasive ear or pulse oximetry for oxygen saturation
Not reimbursed when billed on the same date of service as an E&M service.



99000, 99001
Handling fees
Not separately reimbursed.


99002
Device handling
Not separately reimbursed.


99026, 99027
Hospital-mandated on-call service, in or out of hospital
Not separately reimbursed.


99050
Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g. holidays, Saturday or Sunday), in addition to basic service.
Reimbursed when submitted with 99201-99205; 99211-99215.



99051
Services provided in the office during regularly scheduled evening, weekend or holiday office hours, in addition to basic service.
Reimbursed when submitted with E&M services 99201-99205; 99211-99215.



99053
Services provided between 10 PM and 8 AM at a 24 hour facility in addition to the basic service.
Not separately reimbursed.


99056
Services typically provided in the office, provided out of the office at the request of the patient, in addition to the basis service.
Not separately reimbursed.


99058
Office services provided on an emergency basis in the office which disrupts other scheduled office services, in addition to the basic service.
Not separately reimbursed.


99060
Services provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service.
Not reimbursed when submitted with E&M services 99201-99205 and 99211-99215.


99070
Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)
Not separately reimbursed, use of a specific HCPCS code and/or prior authorization is required for payment consideration.


99075
Medical testimony
Not covered.



99080
Special reports
Not separately reimbursed.


99082
Unusual travel
Not separately reimbursed.


99090
Analysis of data stored in a computer
Not covered.


99143-99145
Moderate sedation
Not separately reimbursed.


99217
Observation Care Discharge Services]


99218 - 99220
Initial observation care


99221 - 99223
Initial hospital care


99231 - 99233
Subsequent hospital care


99234 - 99236
Observation or inpatient care services (including admission and discharge services)


99238
Hospital discharge day management 30 minutes or less


99239
Hospital discharge day management more than 30 minutes


99281 – 99285
Emergency Department
Bill for unscheduled episodic emergency medical care provided in the emergency department

99288
Physician direction of emergency medical systems (EMS) emergency care, advanced live support (ALS)
Bill when the physician is located in a hospital emergency or critical care department and is in two-way voice communication with ambulance or rescue personnel outside the hospital]


99289, 99290
Pediatric care patient transport
Bill one unit with code 99289 for the first 30-74 minutes; bill the number of units that represent each additional 30 minutes of transport time with 99290.



99291, 99292
Critical Care
Bill one unit with code 99291 for the first 30-74 minutes, bill the number of units that represent each additional 30 minutes of critical care time with 99292.


99293, 99294
Inpatient pediatric critical care
Bill critical care services provided for children age 29 days through 24 months old, per day.


99295, 99296
Inpatient neonatal critical care
Bill critical care services provided to neonate 28 days of age or less using the appropriate neonatal intensive care code; bill one unit per day.



99298 - 99300
Intensive (non-critical) low birth weight services
Bill with appropriate code by weight. Bill one unit per day.


99304 - 99306
Initial nursing facility care

99307 - 99310
Subsequent nursing facility care

99315 - 99316
Nursing facility discharge services

99318
Evaluation and Management of patient involving an annual nursing facility assessment.
Do not report 99318 on the same date of service as nursing facility services codes 99304-99316.


99341 - 99350
Physician home services

+99354 - +99355
Prolonged services, face-to-face, office or outpatient setting
For the first 60 minutes, use +99354 in conjunction with 99201-99215, 99304-99350
For each additional 30 minutes, use +99355 in conjunction with 99354


+99356 - +99357
Prolonged services, face-to-face, inpatient setting
For the first 60 minutes, use +99356 in conjunction with 99221-99233
For each additional 30 minutes, use +99357 in conjunction with +99356


99360
Standby services
Not separately reimbursed



99363 - 99364
Anti-coagulation management


99366
Medical team conference, interdisciplinary team, face-to-face, patient and/or family, 30 minutes or more, with participation by non-physician practitioner Not separately reimbursed Documentation requirements: must show when conference starts and ends.

99367
Medical team conference, interdisciplinary team, patient and/or family not present, 30 minutes or more, participation by physician Not separately reimbursed
Documentation requirements: must show when conference starts and ends.


99368
Medical team conference, participation by non-physician qualified health care professional
Not separately reimbursed
Documentation requirements: must show when conference starts and ends.


99401 - 99404
Preventive medicine, individual counseling
Mutually exclusive if billed with another E&M code.


99406 - 99407 (only covered by MassHealth and Senior Plans)
Behavior change interventions, individual (smoking and tobacco cessation)
Not separately reimbursed


99408 - 99409
Behavior change interventions, individual (alcohol and/or substance (other than tobacco) abuse structured screening)
Not separately reimbursed
Document requirements: must use the standardized 10 item screening questionnaire. www.projectcork.org/clinical_tools


99441 - 99443
Telephone management
FCHP reimburses for telephone calls (99441-99443) with behavioral health diagnosis codes twice per calendar year. Refer to

Team Conferences and Telephone Services Payment Policy.

A. Use of Critical Care Codes

Pay for services reported with CPT codes 99291 and 99292 when all the criteria for critical care and critical care services are met. 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.

Critical care involves high complexity decision making to assess, manipulate, and support vital system functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.

Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present.

Providing medical care to a critically ill, injured, or post-operative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements.

Critical care is usually, but not always, given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit, or the emergency department. However, payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care.

Consult the American Medical Association (AMA) CPT Manual for the applicable codes and guidance for critical care services provided to neonates, infants and children.



B. Critical Care Services and Medical Necessity

Critical care services must be medically necessary and reasonable. Services provided that do not meet critical care services or services provided for a patient who is not critically ill or injured in accordance with the above definitions and criteria but who happens to be in a critical care, intensive care, or other specialized care unit should be reported using another appropriate E/M code (e.g., subsequent hospital care, CPT codes 99231 - 99233).

As described in Section A, 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).


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