CRITICAL CARE SERVICES (CODES 99291-99292)

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 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).

Chronic Illness

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:

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)

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