Hospital Critical Care CPT® Coding…Time to Take Closer Look!?

hospital critical care emergency room sign

In the hospital outpatient coding world, we find the emergency room providing “Critical Care” services.  Having a clear understanding of the documentation and medical coding is vital to compliance and accurate reimbursement. Under Outpatient Prospective Payment System (OPPS), there are two Critical Care codes that can be assigned and reported, but only one is directly associated with specific hospital reimbursement. Now is the time to take a closer look at this medical coding area.

Hospital emergency rooms encounter patients with a wide variety of illnesses and injuries, from an earache to a life-threatening auto accident in which the individual sustains serious injuries. When the clinical situation is at a high intensity of care due to the signs or symptoms of multiple organ system failure, and/or imminent life-threatening situation, the encounter service may represent “Critical Care”. This hospital “Critical Care” may be associated with a Trauma Activation if your hospital has that designation.

There are occasions when the clinical documentation is not supportive of Critical Care due to a lack of specific documentation elements or information in the provider report or note. The documentation we will also use for Critical Care can include the “Nursing Documentation”. This documentation can support a Critical Care level of service for the hospital. In fact, under OPPS, the language states, “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.”

In addition, we all need to remember that all clinical documentation must be truthful and compliant. However, without such complete and specific documentation the hospital will have to assign an Evaluation and Management level 1-V code. Keep in mind that Critical Care for the provider (physician) can be given in any setting, not just the emergency room, but we are talking about the “Hospital” coding in this article, so it is the Critical Care provided in the ED or the Trauma Unit of the ED.

The Critical Care service is, “the direct delivery by a physician(s) or other qualified healthcare professional (QHP) of medical care for a critically ill/injured patient in which there is acute impairment of one or more vital organ systems, such that there is a probability of imminent or life-threatening deterioration of the patient’s condition. It involves high complexity decision making to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition”.

Think about the associated documentation with the above statement and what it should/would include. Also keep in mind that vital organ system failure includes, but is not limited to, failure of the central nervous, circulatory, or respiratory systems; kidneys; liver; shock; and other metabolic processes.

Under CPT ® the description for Critical Care is states as the following:

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 critical injured patient; each additional 30 minutes (list separately in addition to code for primary service)

Because the Critical Care service is time based, documenting the time is essential. This is often documented in total minutes within the medical record. The Critical Care service is also provided to the “critically ill or critically injured patient”, so again it is essential that the documentation state this or reflect this clearly and accurately.

Elements that really help to meet the Critical Care service include but are not limited to the following:

  • Statement of life-threatening injury or illness
  • Face to face or one-on one (1:1) care was provided
  • Total time for the Critical Care in minutes

The hospital critical care documentation should reflect at least the following:

  • Highly complex clinical decisions usually based on interpretation of complex data and use of advanced technology.
  • Clinical decisions addressing organ system failure, or the prevention of further life-threatening deterioration.
  • Both the clinical status and the care rendered by the provider(s) are critical in nature.
  • The intensity of care AND the time spent meet the critical care definition.


A key to accurate and complaint Critical Care coding is having a thorough description and statement of the Critical Care provided. Here is an example I’ve seen that is good and meets all requirements:

This patient met clinical critical injury/illness criteria to receive a (Full)/(Partial) multidisciplinary trauma team response. By meeting these criteria, there is a high probability that this patient has an eminent life-threatening injury requiring high-complexity decision-making to assess, manipulate, and support vital system function(s) to diagnose and treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition. I provided direct 1:1 face-to-face critical care to this patient for a total of XX minutes.

A few tips to remember are:

  • The Hospital CRITICAL CARE can be provided by ED/Trauma, Physician/Surgeon, ED/Trauma Nursing and/or other Ancillary Staff, and the care MUST BE DOCUMENTED in the medical record.
  • The Hospital CRITICAL CARE documentation MUST be with one-on-one (1:1) care AND describe the severity of the patient, describe the care provided AND the total minutes of Critical Care to support the coding/billing.
  • For accurate coding/billing…If the Physician and hospital staff or multiple staff members are simultaneously engaged in one-on-one care, the Hospital Critical Care time would be counted once.

Your Medicare Administrative Contractor (MAC) may have some guidance and information posted on their website, so take some time to check into that as well. 

It’s that time, yes, audit time, start now and plan to conduct a review (audit) of your hospital ED and/or Critical Care documentation and coding. To learn more about how MRA can help your hospital, contact our experts today.

References: CMS OPPS; CPT Critical Care

CPT is a trademark of the AMA.

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