In order to reliably and consistently determine that delivery of critical care services rather than other evaluation and management (E/M) services is medically necessary, both of the following medical review criteria must be met in addition to the Current Procedural Terminology (CPT) Manual definitions:
Clinical condition criterion - There is a high probability of sudden, clinically significant, or life threatening deterioration in the patient’s condition which requires the highest level of physician preparedness to intervene urgently.
Treatment criterion - Critical care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient’s condition.
Providing medical care to a critically ill patient should not be automatically classified as a critical care service for the sole reason that the patient is critically ill.
The provider’s service must be medically necessary and meet the definition of critical care services as described below in order to be considered covered.
Critical Care Definition - Critical care is the direct delivery by a physician(s) of medical care for a critically ill or injured patient.
The care of such patients involves decision making of high complexity to assess, manipulate, and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple vital organ system failure or to prevent further deterioration.
It may require extensive interpretation of multiple databases and the application of advanced technology to manage the patient.
Critical care services include but are not limited to, the treatment or prevention or further deterioration of central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic or respiratory failure, post-operative complications, or overwhelming infection.
Since critical care is a time-based code, the physician’s progress note must contain documentation of the total time involved providing critical care services.
Critical care codes 99291 (evaluation and management of the critically ill or critically injured patient, first 30-74 minutes) and 99292 (critical care, each additional 30 minutes) are used to report the total duration of time spent by a provider providing critical care services to a critically ill or critically injured patient, even if the time spent by the provider on that date is not continuous.
For any given period of time spent providing critical care services, the provider must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.
Time involved performing procedures that are not bundled into critical care (i.e., billed separately) may not be included and counted toward critical care time.
The provider’s progress note must document that time involved in the performance of separately billable procedures was not counted toward critical care time.
Time involved with family members or other surrogate decision makers, whether to obtain a history or to discuss treatment options may be counted toward critical care time only when:
The patient is unable or incompetent to participate in giving a history and/or making treatment decisions,
The discussion is absolutely necessary for treatment decisions under consideration that day, and
All of the following are documented in the provider’s progress note for that day:
The patient was unable or incompetent to participate in giving history and/or making treatment decisions, as appropriate,
The necessity of the discussion (e.g., no other source was available to obtain a history” or “because the patient was deteriorating so rapidly needed to discuss treatment options with family immediately”),
The treatment decisions for which the discussion was needed, and
The substance of the discussion as related to the treatment decision.
The physician’s progress note must link the family discussion to a specific treatment issue and explain why the discussion was necessary on that day.
All other family discussions, no matter how lengthy, may not be counted towards critical care time.
CPT code 99291 (evaluation and management of the critically ill or critically injured patient, first 30-74 minutes) to report the first 30-74 minutes of critical care on a given calendar date of service. You can only use this code once per calendar date to bill for care provided for a particular patient by the same physician or physician group of the same specialty.
CPT code 99292 (critical care, each additional 30 minutes) is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care.
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.
Total Duration of Critical Care
Appropriate CPT 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 x 1 and 99292 x 2
135- 164 minutes
99291 x 1 and 99292 x 3
165- 194 minutes
99291 x 1 and 99292 x 4
195 minutes or longer
99291- 99292 as appropriate (per the above illustrations)
Services must be medically necessary and meet the requirements of critical care services. Care provided to patients that do not meet all of the criteria for critical care are reported using the appropriate E/M code depending on the level of service provided.
Full Attention of Rendering Provider:
Services require the full attention of the provider rendering the service.
All time reported should represent the time the provider actually was evaluating, managing and providing patient critical care.
Time must be spent at the patient’s immediate bedside or elsewhere on the floor, or unit, so long as the provider is immediately available to the patient.
For any given period of time spent providing critical care services to a patient, the practitioner cannot provide services to any other patient during the same time period.
Only one physician or non-physician practitioner 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.
Critical care is a time based service:
Time may be continuous or an aggregate of intermittent time spent by members of the same group and same specialty.
Progress notes must document the total time the critical care services were provided for each date and encounter entry. When multiple physicians are involved, the documentation must support the medical necessity of the critical care services rendered by each physician.
Time requirement of the initial critical care service must be met by only one physician or non-physician practitioner.
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.
Services may not be shared/split between a physician and non-physician practitioner.
Coding critical care services:
CPT code 99291 is used to report the first 30 - 74 minutes of critical care on a given calendar date of service.
Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician.
CPT code 99291 should be used once per calendar date per patient by the same physician or physician group of the same specialty.
Non-physician practitioners of the same group:
Physician time may not be combined with a non-physician practitioner of the same group practice.
Time is billed separately from the physician using the appropriate code.
May not bill the initial critical care code on the same day as the physician (e.g., if the physician provides 30 - 74 minutes of critical care services, the non-physician practitioner will bill CPT code 99292 for the additional time up to 30 minutes.)
Physicians of a different specialty may each report CPT code 99291 if they 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)
Critical care of less than 30 minutes total duration on a given calendar date is not reported separately using the initial critical care CPT code (99291). This service should be reported using another appropriate E/M code [ensuring all components of the CPT descriptor are met] such as subsequent hospital care.
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:
Reporting CPT code 99291 is a prerequisite to reporting CPT code 99292.
Includes “staff coverage” or “follow-up” even if a different specialty.
Must bill one unit for every 30 minutes (e.g., an additional 60 minutes would be 2 units).