Critical Care Services Provided by Physicians in Group Practice(s)

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). Each physician must accurately report the service(s) he/she provided to the patient in accordance with any applicable global surgery rules or concurrent care rules.

CPT Code 99291

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 exam 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.

CPT Code 99292

Subsequent critical care visits performed on the same calendar date are reported using CPT code 99292. The service may represent aggregate time met by a single physician or physicians in the same group practice with the same medical specialty in order to meet the duration of minutes required for CPT code 99292. The aggregated critical care visits must be medically necessary and each aggregated visit must meet the definition of critical care in order to combine the times.

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. Medicare payment policy states that physicians in the same group practice who are in the same specialty must bill and be paid as though each were the single physician. (Refer to the Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, §30.6.)

Physician specialty means the self-designated primary specialty by which the physician bills Medicare and is known to the contractor that adjudicates the claims. Physicians in the same group practice who have different medical specialties may bill and be paid without regard to their membership in the same group. For example, if a cardiologist and an endocrinologist are group partners and the critical care services of each are medically necessary and not duplicative, the critical care services may be reported by each regardless of their group practice relationship.

Two or more physicians in the same group practice who have different specialties and who provide critical care to a critically ill or critically injured patient may not in all cases each report the initial critical care code (CPT 99291) on the same date. When the group physicians are providing care that is unique to his/her individual medical specialty and 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 “follow-up” for each other after the first hour of critical care services was provided on the same calendar date by the previous group clinician (physician or qualified NPP), the subsequent visits by the “covering” physician or qualified NPP in the group shall be billed using CPT critical care add-on code 99292. The appropriate individual NPI number shall be reported on the claim. The services will be paid at the specific physician fee schedule rate for the individual clinician (physician or qualified NPP) billing the service.



Clinical Examples of Critical Care Services

1. Drs. Smith and Jones, pulmonary specialists, share a group practice. On Tuesday Dr. Smith provides critical care services to Mrs. Benson who is comatose and has been in the intensive care unit for 4 days following a motor vehicle accident. She has multiple organ dysfunction including cerebral hematoma, flail chest and pulmonary contusion. Later on the same calendar date Dr. Jones covers for Dr. Smith and provides critical care services. Medically necessary critical care services provided at the different time periods may be reported by both Drs. Smith and Jones. Dr. Smith would report CPT code 99291 for the initial visit and Dr. Jones, as part of the same group practice would report CPT code 99292 on the same calendar date if the appropriate time requirements are met.

2. Mr. Marks, a 79 year old comes to the emergency room with vague joint pains and lethargy. The ED physician evaluates Mr. Marks and phones his primary care physician to discuss his medical evaluation. His primary care physician visits the ER and admits Mr. Marks to the observation unit for monitoring, and diagnostic and laboratory tests. In observation Mr. Marks has a cardiac arrest. His primary care physician provides 50 minutes of critical care services. Mr. Marks’ is admitted to the intensive care unit. On the same calendar day Mr. Marks’ condition deteriorates and he requires intermittent critical care services. In this scenario the ED physician should report an emergency department visit and the primary care physician should report both an initial hospital visit and critical care services.

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.

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

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 (refer to the Medicare Benefit Policy Manual, Pub. 100- 02, Chapter 15, §30 for concurrent care policy discussion).

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 (§30.6.5).

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 decisionmakers 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).

Hours and Days of Critical Care that May Be Billed

Critical care service is a time-based service provided on an hourly or fraction of an hour basis. Payment should not be restricted to a fixed number of hours, a fixed number of physicians, or a fixed number of days, on a per patient basis, for medically necessary critical care services. Time counted towards critical care services may be continuous or intermittent and aggregated in time increments (e.g., 50 minutes of continuous clock time or (5) 10 minute blocks of time spread over a given calendar date). Only one physician may bill for critical care services during any one single period of time even if more than one physician is providing care to a critically ill patient.

For Medicare Part B physician services paid under the physician fee schedule, critical care is not a service that is paid on a “shift” basis or a “per day” basis. Documentation may be requested for any claim to determine medical necessity. Examples of critical care billing that may require further review could include: claims from several physicians submitting multiple units of critical care for a single patient, and submitting claims for more than 12 hours of critical care time by a physician for one or more patients on the same given calendar date. 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.

The CPT code 99291 is used to report the first 30 – 74 minutes of critical care on a given calendar date of service. It should only be used once per calendar date per patient by the same physician or physician group of the same specialty. CPT code 99292 is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care (See table below). 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.


Clinical Example of Correct Billing of Time:

A patient arrives in the emergency department 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 emergency department services. The cardiologist may report the 35 minutes of critical care services (also CPT code 99291) provided in the ED. Additional critical care services by the cardiologist in the CCU may be reported on the same calendar date using 99292 or another appropriate E/M code depending on the clock time involved.

Counting of Units of Critical Care Services

The CPT code 99291 (critical care, first hour) is used to report the services of a physician providing full attention to a critically ill or critically injured patient from 30-74 minutes on a given date. Only one unit of CPT code 99291 may be billed by a physician for a patient on a given date. Physicians of the same specialty
within the same group practice bill and are paid as though  they were a single physician and would not each report CPT 99291on the same date of service.

The following illustrates the correct reporting of critical care services:


Total Duration of Critical Care Codes

Less than 30 minutes 99232 or 99233 or other appropriate E/M code
30 – 74 minutes 99291 x 1
75 – 104 minutes 99291 x 1 and 99292 x 1
105 – 134 minutes 99291 x1 and 99292 x 2
135 – 164 minutes 99291 x 1 and 99292 x 3
165 – 194 minutes 99291 x 1 and 99292 x 4
194 minutes or longer 99291 – 99292 as appropriate (per the above illustrations)

Critical Care Services and Other Evaluation and Management Services Provided on Same Day 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 evaluation and management 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 evaluation and management 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.

Critical Care Services and Other Procedures Provided on the Same Day by the Same Physician as Critical Care Codes 99291 – 99292

The following services when performed on the day a physician bills for critical care are included in the critical care service and should not be reported separately:

• The interpretation of cardiac output measurements (CPT 93561, 93562);
• Chest x-rays, professional component (CPT 71010, 71015, 71020);
Blood draw for specimen (CPT 36415);
• Blood gases, and information data stored in computers (e.g., ECGs, blood pressures, hematologic data-CPT 99090);
• Gastric intubation (CPT 43752, 91105);
Pulse oximetry (CPT 94760, 94761, 94762);
• Temporary transcutaneous pacing (CPT 92953);
• Ventilator management (CPT 94002 – 94004, 94660, 94662); and
• Vascular access procedures (CPT 36000, 36410, 36415, 36591, 36600).

No other procedure codes are bundled into the critical care services. Therefore, other medically necessary procedure codes may be billed separately.