Critical Care Overview

In this article we will highlight some key elements for Critical Care coding since these codes are watched closely by insurance payors. What is the definition of Critical Care? Per American Medical Association (AMA) CPT Professional 2021 codebook, critical care is defined as “…the direct delivery by a physician(s) or other qualified healthcare professional of medical care for a critically ill or critically injured patient.” The critical illness or injury would acutely impair one or more vital organ systems (i.e. central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure) to such a degree where there is high likelihood of imminent or life-threatening deterioration in the patient’s condition. The provider would treat the critical illness using “high complexity decision making to assess, manage, and support vital systems to treat single or multiple vital organ system failures and/or prevent further life-threatening deterioration of the patient’s condition.” (AMA CPT Professional Edition 2021 pgs. 31-32). Critical care services require the personal attention of the provider and must be provided at the patient’s bedside or on the floor/unit where the patient is located (immediately available and doing work related to the patient). Critical care services can be provided anywhere as long as the definition of critical care is met. Being called to the bedside emergently is not the only requirement to support reporting critical care services and the provider’s documentation should clearly reflect the severity of the illness/injury and what services were provided at that moment to support the billing of critical care.

There are two primary adult critical care codes:

  • 99291 Critical care, evaluation, and management of the critically ill or critically injured patient, first 30 to 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 the code for the primary service)

(If less than 30 minutes of critical time is documented then an appropriate E/M code would be reported)

99291 may be used only once per day by a single provider or by multiple providers within the same group, even if the time spent is not continuous. The initial 30 minutes of critical care (99291) needs to be performed by a single provider. Code 99292 is an add-on code and may be used for additional time spent providing critical care after the first 74 minutes. You can find a helpful grid in your CPT book to help determine how many units of 99292 are billed based on the total time documented.

Keep in mind critical care can be continuous, intermittent, or accumulated. More than one provider (usually different specialties) can provide critical care services if their service meets the requirements of critical care and is medically necessary. It cannot be a duplication of care; documentation must reflect how the two physicians focused on different issues of care and clearly state their individual time (time cannot overlap). Physicians of the same specialty within the same group practice may bill and are paid as though they were a single physician (NPP and physician time cannot be combined) and each provider’s critical care time needs to be documented separately. If two physicians of the same group provide critical care throughout the day, then their time is added together and reported under a single provider or broken out with 99291 for Dr. and 99292 for Dr. B if time is over 74 minutes. It is recommended that each provider documents a note and time for each critical care session(s) they performed during a calendar day. This helps paint the picture of how sick/injured the patient is, what the provider had to do throughout the day to prevent further deterioration.

99291 and 99292 have good reimbursement rates and are scrutinized by Medicare and other payors. Make sure your documentation supports the code(s).


References: AMA’s Current Procedural Terminology 2021 codebook; Medicare Claims Processing Manual; Society of Critical Care Medicine

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