Providers in AR, CO, LA, MS, NM, OK, TX, Indian Health & Veteran Affairs
Effective January 1, 2022, critical care services are reported by a physician or other qualified health care provider for critically ill or injured patients. Critical illnesses or injuries are defined as those with acute impairment to one or more vital organ systems with an increased risk of imminent or life-threatening health deterioration. Critical care services require direct patient/provider involvement with highly complex decision-making in order to evaluate, control and support vital systems functions in treating one or more vital organ system failures and/or to avoid further decline of the patient's condition. 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.
Generally, critical care services necessitate the interpretation of many physiologic parameters and/or other applications of advanced technology as available in a critical care unit, pediatric intensive care unit, respiratory care unit, in an emergency facility, patient room or other hospital department. However, in emergent situations, critical care may be provided where these elements are not available. Critical care may be provided so long as the patient's condition continues to warrant the level of care according to the criteria described. Care provided to patients anywhere, including a critical care unit, that does not fit the above definitions for critical care is reported using other E/M codes, as appropriate.
CPT® code 99291 is critical care, evaluation and management of the critically ill or critically injured patient for the first 30–74 minutes.
CPT® code 99292 is critical care, evaluation and management of the critically ill or critically injured patient for each additional 30 minutes (list separately in addition to code for primary service).
The Medicare Claims Processing Manual, Chapter 12, Section 30 (PDF) contains the Calendar year 2022 changes to Medicare Part B Payment Policies Final Rule (CMS-1751-F) for Critical Care Evaluation and Management (E/M) services.
Critical care services and neonatal intensive care CPT® codes 99291–99292
Things to know
(Visit CMS.GOV for additional information)
Critical care-bundled services
Bundled services that are included by CPT in critical care services (and therefore not separately payable) include interpretations of cardiac output measurements, chest X-rays, pulse oximetry, blood gases and other physiologic data such as ECGs, blood pressures, hematologic data; gastric intubation, temporary transcutaneous pacing, ventilator management, and vascular access procedures
Critical care by a single physician or NPP
CPT codes 99291 and 99292 will be used to report the total duration of time spent by the physician or NPP providing critical care services to a critically ill or critically injured patient, even if the time spent by the practitioner on that date is not continuous
Noncontinuous time for medically necessary critical care services may be aggregated
Critical care visits furnished concurrently by different specialties
Concurrent care is when more than one physician renders services that are more extensive than consultative services during a period of time
The reasonable and necessary services of each physician furnishing concurrent care are covered when each plays an active role in the patient’s treatment
In the context of critical care services, a critically ill patient may have more than one medical condition requiring diverse, specialized medical services, and requiring more than one practitioner, each having a different specialty, playing an active role in the patient’s treatment
Medicare policy allows critical care visits furnished concurrently to the same patient on the same date by more than one practitioner in more than one specialty, regardless of group affiliation, if the services meets the definition of critical care, is medically necessary, and is not duplicative of other services
Critical care furnished concurrently by practitioners in the same specialty and same group (follow-up care)
Physicians or NPPs in the same specialty and in the same group may provide concurrent follow-up care, such as a critical care visit subsequent to another practitioner’s critical care visit
This may be as part of continuous staff coverage or follow-up care to critical care services furnished earlier in the day on the same calendar date
CPT code 99291 may not be reported more than once for the same patient on the same date. If multiple practitioners are involved in the provision of 99291 services, the total time spent by those practitioners is aggregated toward the time requirement for this service. Code 99292 is reported when an additional 30 minutes of critical care services have been furnished to same patient on the same date.
Any aggregated time spent on critical care services must be medically necessary and must meet the definition of critical care
Medicare classifies NPPs in a specialty that is not the same as a physician. In these instances, guidance regarding split (or shared) critical care services must be followed.
Split (or shared) critical care visits
The billing practitioner (physician or NPP) bills the initial service (CPT 99291) and any add-on codes(s) for additional time (CPT 99292) based on substantive provision of those services
The substantive portion for critical care services is defined as more than half of the total time spent by the physician or NPP beginning January 1, 2022
In the context of critical care, split (or shared) visits occur when the total critical care service time furnished by a physician and NPP in the same group on a given calendar date to a patient is summed, and the practitioner who furnishes the substantive portion of the cumulative critical care time reports the critical care service(s)
Critical care services can include additional activities that are bundled into the critical care visit code(s). There is a unique listing of these qualifying activities which are described in the prefatory language for critical care services in the CPT Codebook.
To bill split (shared) critical care services, the billing physician or NPP first reports CPT code 99291 and, if 104 or more total minutes are spend providing critical care, the billing physician or NPP reports one or more units of CPT code 99292. Modifier -FS (split or shared E/M visit) must be appended to the critical care CPT code(s) on the claim.
When two or more practitioners spend time jointly meeting with or discussing the patient’s care, that time can be counted only once for purposes of reporting the split (or shared) critical care visit
Critical care and other same-day evaluation and management (E/M) visits
Physicians in the same group who are in the same specialty must bill and be paid for services under the PFS as though they were a single physician
If more than one E/M visit is provided on the same date to the same patient by the same physician, or by more than one physician in the same specialty in the same group, only one E/M service may be reported, unless the E/M services are for unrelated problems
Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. This general policy is intended to ensure that multiple E/M visits for a patient on a single day are medically necessary and not duplicative.
In situations when a patient receives another E/M visit on the same calendar date as critical care services, both may be billed (regardless of practitioner specialty or group affiliation) as long as the medical record documentation notes that 1) the other E/M visit was provided before the critical care and at a time when the patient did not require critical care; 2) the services were medically necessary; and 3) the services were separate and distinct with no duplicative elements from the critical care services occurring later in the day. Additionally, the modifier -25 should be appended to the critical care services on the claim for this day.
Critical care visits and global surgery
When a critical care visit is unrelated to the procedure with a global surgical period, critical care visits may be paid separately in addition to the procedure
Preoperative and/or postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the full attention of the physician, and the critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed (for example, trauma or burn cases)
When the critical care service is unrelated to the procedure, append the modifier -FT (unrelated evaluation and management (E/M) visit during a postoperative period, or on the same day as a procedure or another E/M visit
Medical record documentation
Documentation needs to indicate that the services furnished to the patient, including any concurrent care by the practitioners, are medically reasonable and necessary for the diagnosis and/or treatment of illness and/or injury or to improve the functioning of a malformed body member
To support coverage and payment determinations regarding concurrent care, services must be sufficiently documented to allow a medical reviewer to determine the role each practitioner played in the patient’s care (that is, the condition or conditions for which the practitioner treated the patient)
When critical care is furnished in conjunction with a global procedure, the documentation must support that the critical care was unrelated to the procedure
Documentation is needed to support coverage and payment for split (shared) critical care services as provided by the practitioner who performs the substantive portion of those services. Please refer to the split (or shared) critical care services section above. Only distinct time can be counted. When the sharing practitioners are jointly providing services in conjunction with one another, only the time of one of the practitioners can be counted. One of the practitioners must have face-to-face contact with the patient. The substantive portion is determined by the proportion of total time, not whether the time involves patient contact.
For split (or shared) critical care services, the documentation in the medical record must identify the physician and nonphysician practitioner who performed the visit. The individual who performed the substantive time portion of the service will be the one who bills for the service and that individual must sign and date the medical record. Best practice is for each practitioner to note the amount of time committed to the provided service.