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Critical Care FAQ

  • What is the CPT definition of critical care service (99291 and 99292)?
    Recommendations
    Answer

    CPT currently defines a critical illness or injury as an illness or injury that 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 services are defined as a physician's direct delivery of medical care for a critically ill or critically injured patient. It involves decision making of high complexity to assess, manipulate, and support 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.

    CMS adds that in order to qualify as critical care for Medicare patients, "the 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."

    Answer

    CPT currently defines a critical illness or injury as an illness or injury that 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 services are defined as a physician's direct delivery of medical care for a critically ill or critically injured patient. It involves decision making of high complexity to assess, manipulate, and support 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.

    CMS adds that in order to qualify as critical care for Medicare patients, "the 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."

  • How does Medicare's addressing of CC differ from CPT's?
    Recommendations
    Answer

    In 2022 CMS now states they agree with CPT.

    Answer

    In 2022 CMS now states they agree with CPT.

  • How is physician time measured for the purpose of determining the correct critical care code(s)?
    Recommendations
    Answer

    The duration of critical care services for both CPT and Medicare is based on the physician’s documentation of total time spent evaluating, managing, and providing care to the critical patient, as well as time spent in documenting such activities. During each moment of this accrued total time, the physician must devote full attention to the particular patient. This time may be spent at the patient’s immediate bedside or elsewhere on the unit, so long as the physician is immediately available to the patient. 

    Physician time for critical care services encompasses time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere. For example, time spent can be at the bedside, reviewing test results, discussing the case with staff, documenting the medical record and time spent with family members (or surrogate decision makers) discussing specific treatment issues when the patient is unable or clinically incompetent to participate in providing history or making management decisions. The "critical care accrual clock" pauses when separately reportable procedures or services are performed; these should not be included in the total time reported as critical care time. Time involved in activities that do not directly contribute to the treatment of the critical patient may not be counted toward the critical care time.

    The critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services, even if the time spent by the physician on that date is not continuous.  Non-continuous time for critical care services may be aggregated for a single date.  CPT code 99291 is used to report the first 30-74 minutes of critical care on a given date.  It should be used only once per date.  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.  (Example: For critical care time of 35 minutes, report 99291 x 1 only.  For critical care time of 115 minutes report 99291 x 1, and 99292 x 2).  Critical care time of less than 30 minutes is not reported using the critical care codes.  Such service should be reported using the appropriate E/M code.

    Only the time-based critical care codes (99291 and 99292) may be reported for services in the ED. The daily neonatal (99468-99469) and pediatric (99471, 99472, 99475 and 99476) critical care codes are only used in the inpatient setting.

    Answer

    The duration of critical care services for both CPT and Medicare is based on the physician’s documentation of total time spent evaluating, managing, and providing care to the critical patient, as well as time spent in documenting such activities. During each moment of this accrued total time, the physician must devote full attention to the particular patient. This time may be spent at the patient’s immediate bedside or elsewhere on the unit, so long as the physician is immediately available to the patient. 

    Physician time for critical care services encompasses time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere. For example, time spent can be at the bedside, reviewing test results, discussing the case with staff, documenting the medical record and time spent with family members (or surrogate decision makers) discussing specific treatment issues when the patient is unable or clinically incompetent to participate in providing history or making management decisions. The "critical care accrual clock" pauses when separately reportable procedures or services are performed; these should not be included in the total time reported as critical care time. Time involved in activities that do not directly contribute to the treatment of the critical patient may not be counted toward the critical care time.

    The critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services, even if the time spent by the physician on that date is not continuous.  Non-continuous time for critical care services may be aggregated for a single date.  CPT code 99291 is used to report the first 30-74 minutes of critical care on a given date.  It should be used only once per date.  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.  (Example: For critical care time of 35 minutes, report 99291 x 1 only.  For critical care time of 115 minutes report 99291 x 1, and 99292 x 2).  Critical care time of less than 30 minutes is not reported using the critical care codes.  Such service should be reported using the appropriate E/M code.

    Only the time-based critical care codes (99291 and 99292) may be reported for services in the ED. The daily neonatal (99468-99469) and pediatric (99471, 99472, 99475 and 99476) critical care codes are only used in the inpatient setting.

  • If the critical care codes address services provided on a single date, what happens if the critical care service extends into another calendar day?
    Recommendations
    Answer

    CPT coding principles require that when a time-dependent service is performed continuously and crosses over midnight the time should be accrued for, and reported as occurring, on the pre-midnight date. However, once the service is disrupted (i.e., becomes non-continuous), then that creates the need for a new initial service on the post-midnight date.  The following examples for critical care are constructed for better contrast, but the coding effects would be similar even if the respective times were hours distant from midnight:

    Scenario 1:  How would you code a patient who presents to the ED at 2335 Day 1, with CC services beginning at that time and performed continuously until 0015 on Day 2, with no more CC services performed on Day 2?

    Answer:  Critical care 99291 can be reported for Day 1.

    Scenario 2:  How would you code a patient who presents to the ED at 2335 Day 1, with CC services beginning at that time and performed continuously until 0015 on Day 2, at which time continuous CC services are interrupted; CC services are reinitiated at 0030 Day 2, with an additional 65 minutes provided on Day 2 following the re-initiation?

    Answer:  Critical care 99291 can be reported for Day 1, and a second 99291 reported for Day 2. 

    Be sure documentation demonstrates the relevant circumstances.

    The CMS Physician Fee Schedule (PFS) for 2022 CMS clarifies and agrees with CPT.

    Answer

    CPT coding principles require that when a time-dependent service is performed continuously and crosses over midnight the time should be accrued for, and reported as occurring, on the pre-midnight date. However, once the service is disrupted (i.e., becomes non-continuous), then that creates the need for a new initial service on the post-midnight date.  The following examples for critical care are constructed for better contrast, but the coding effects would be similar even if the respective times were hours distant from midnight:

    Scenario 1:  How would you code a patient who presents to the ED at 2335 Day 1, with CC services beginning at that time and performed continuously until 0015 on Day 2, with no more CC services performed on Day 2?

    Answer:  Critical care 99291 can be reported for Day 1.

    Scenario 2:  How would you code a patient who presents to the ED at 2335 Day 1, with CC services beginning at that time and performed continuously until 0015 on Day 2, at which time continuous CC services are interrupted; CC services are reinitiated at 0030 Day 2, with an additional 65 minutes provided on Day 2 following the re-initiation?

    Answer:  Critical care 99291 can be reported for Day 1, and a second 99291 reported for Day 2. 

    Be sure documentation demonstrates the relevant circumstances.

    The CMS Physician Fee Schedule (PFS) for 2022 CMS clarifies and agrees with CPT.

  • What are the key documentation requirements for use of the critical care service codes 99291 and 99292?
    Recommendations
    Answer

    Providing medical care to the critical patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements.  The physician medical record documentation must provide substantive information:

    1. The patient’s condition must meet the definition of a critical illness or injury described above.
    2. The total critical care time delivered must be documented and must be a minimum of 30 minutes, exclusive of separately reportable procedure time(s).
    Answer

    Providing medical care to the critical patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements.  The physician medical record documentation must provide substantive information:

    1. The patient’s condition must meet the definition of a critical illness or injury described above.
    2. The total critical care time delivered must be documented and must be a minimum of 30 minutes, exclusive of separately reportable procedure time(s).
  • What are the key performance and documentation requirements for use of the critical care service codes with regard to Medicare's Teaching Physician Criteria?
    Recommendations
    Answer

    Time spent alone by the resident (i.e., performing critical care activities in the absence of the teaching physician) cannot be counted toward critical care time. Only time spent performing critical care activities by the resident and the teaching physician together or the teaching physician alone can be counted toward critical care time.

    The teaching physician may tie into the resident’s documentation and may refer to the resident’s documentation for specific patient history, physical findings and medical assessment. However, the teaching physician must still document a statement of the total time the teaching physician personally spent providing critical care, that the patient was critically ill when the teaching physician saw the patient, what made the patient critically ill, and the nature of the treatment and management provided by the teaching physician.

    The following vignette is provided by CMS as an example of acceptable documentation:

    "Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident’s documentation and I agree with the resident’s assessment and plan of care."

    See CMS Transmittal 1548 for further details.

    Answer

    Time spent alone by the resident (i.e., performing critical care activities in the absence of the teaching physician) cannot be counted toward critical care time. Only time spent performing critical care activities by the resident and the teaching physician together or the teaching physician alone can be counted toward critical care time.

    The teaching physician may tie into the resident’s documentation and may refer to the resident’s documentation for specific patient history, physical findings and medical assessment. However, the teaching physician must still document a statement of the total time the teaching physician personally spent providing critical care, that the patient was critically ill when the teaching physician saw the patient, what made the patient critically ill, and the nature of the treatment and management provided by the teaching physician.

    The following vignette is provided by CMS as an example of acceptable documentation:

    "Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident’s documentation and I agree with the resident’s assessment and plan of care."

    See CMS Transmittal 1548 for further details.

  • Can a critical care service code be reported with an E/M code for a non-Medicare patient cared for by the same physician on the same calendar day?
    Recommendations
    Answer

    Yes, CPT allows for reporting both an E/M service and a critical care service on the same day. Additionally, CPT does not distinguish as to site of service or which service comes first.

    Some payers may require the -25 modifier be attached to the non-critical care EM service (see below).

    Answer

    Yes, CPT allows for reporting both an E/M service and a critical care service on the same day. Additionally, CPT does not distinguish as to site of service or which service comes first.

    Some payers may require the -25 modifier be attached to the non-critical care EM service (see below).

  • Can a critical care service code be reported with an E/M code for a Medicare patient cared for by the same physician on the same calendar day?
    Recommendations
    Answer

    For 2022 CMS changed its prior policy that had disallowed the reporting of both a 9928x code and critical care on the same day.  CMS now has a policy that allows the reporting of critical care services that are provided after an ED E/M service is complete but not the other way around.

    In other words, if a Medicare patient presents to the emergency department and receives ED workup that is reported with ED E/M codes 99281-99285, and later, on the same date requires critical care services, according to CMS in 2022 the ED physician can report both the 9928x service and critical care. But if a patient presents who received critical care services upon arrival an ED E/M may not be reported by the same physician in the same group for the same encounter if additional ED services are proved after the patient is stabilized. In that scenario, only report either the ED E/M service or the critical care service -- but not both.

    CMS has requested that modifier -25 be utilized when both 9928x and critical care services are provided on the same date by the same group.

    Answer

    For 2022 CMS changed its prior policy that had disallowed the reporting of both a 9928x code and critical care on the same day.  CMS now has a policy that allows the reporting of critical care services that are provided after an ED E/M service is complete but not the other way around.

    In other words, if a Medicare patient presents to the emergency department and receives ED workup that is reported with ED E/M codes 99281-99285, and later, on the same date requires critical care services, according to CMS in 2022 the ED physician can report both the 9928x service and critical care. But if a patient presents who received critical care services upon arrival an ED E/M may not be reported by the same physician in the same group for the same encounter if additional ED services are proved after the patient is stabilized. In that scenario, only report either the ED E/M service or the critical care service -- but not both.

    CMS has requested that modifier -25 be utilized when both 9928x and critical care services are provided on the same date by the same group.

  • According to CPT which procedure codes are considered to be bundled into the critical care code?
    Recommendations
    Answer

    The following services are included in "critical care clock time” when performed during the critical period by the same physician(s) providing critical care and should not be reported separately:

    1. the interpretation of cardiac output measurements (CPT 93598)
    2. pulse oximetry (CPT 94760, 94761, 94762)
    3. chest x-rays, professional component (CPT 71045, 71046)
    4. blood gases, and collection and interpretation of physiologic (eg, ECGs, blood pressures, hematologic data)
    5. gastric intubation (CPT 43752, 43753)
    6. transcutaneous pacing (CPT 92953)
    7. ventilator management (CPT 94002-94004, 94660, 94662)
    8. and vascular access procedures (CPT 36000, 36410, 36415, 36591, 36600)

    Any services performed that are not listed above may be reported separately.  (see FAQ 10)

    Answer

    The following services are included in "critical care clock time” when performed during the critical period by the same physician(s) providing critical care and should not be reported separately:

    1. the interpretation of cardiac output measurements (CPT 93598)
    2. pulse oximetry (CPT 94760, 94761, 94762)
    3. chest x-rays, professional component (CPT 71045, 71046)
    4. blood gases, and collection and interpretation of physiologic (eg, ECGs, blood pressures, hematologic data)
    5. gastric intubation (CPT 43752, 43753)
    6. transcutaneous pacing (CPT 92953)
    7. ventilator management (CPT 94002-94004, 94660, 94662)
    8. and vascular access procedures (CPT 36000, 36410, 36415, 36591, 36600)

    Any services performed that are not listed above may be reported separately.  (see FAQ 10)

  • Does Medicare differ from CPT in the way it addresses bundling of critical care services and procedures?

    Recommendations
    Answer

    Medicare bundles the same services included in critical care by CPT (see FAQ 9 above) when performed by the same physician(s) reporting critical care. In 2022 CMS requires modifier “FT” be appended for procedures with a global period, and a 25 modifier for an E/M service unrelated to the procedure.

    Answer

    Medicare bundles the same services included in critical care by CPT (see FAQ 9 above) when performed by the same physician(s) reporting critical care. In 2022 CMS requires modifier “FT” be appended for procedures with a global period, and a 25 modifier for an E/M service unrelated to the procedure.

  • What are some examples of procedures that could be billed separately from critical care?
    Recommendations
    Answer

    The "critical care accrual clock" pauses when performing non-bundled, separately billable procedures.  In other words, time spent performing these procedures should not be included in the total critical care time reported.  Examples of common procedures that may be reported separately for a critically ill or injured patient include (but not limited to):

    1. CPR (92950) (while being performed)
    2. Endotracheal intubation (31500)
    3. Central line placement (36555, 36556)
    4. Intraosseous placement (36680)
    5. Tube thoracostomy (32551)
    6. Temporary transvenous pacemaker (33210)
    7. Electrocardiogram - routine ECG with at least 12 leads; interpretation and report only (93010)
    8. Elective electrical cardioversion (92960)

    This list is not exhaustive but merely provides examples of separately billable procedures that may be reported in addition to critical care.

    Answer

    The "critical care accrual clock" pauses when performing non-bundled, separately billable procedures.  In other words, time spent performing these procedures should not be included in the total critical care time reported.  Examples of common procedures that may be reported separately for a critically ill or injured patient include (but not limited to):

    1. CPR (92950) (while being performed)
    2. Endotracheal intubation (31500)
    3. Central line placement (36555, 36556)
    4. Intraosseous placement (36680)
    5. Tube thoracostomy (32551)
    6. Temporary transvenous pacemaker (33210)
    7. Electrocardiogram - routine ECG with at least 12 leads; interpretation and report only (93010)
    8. Elective electrical cardioversion (92960)

    This list is not exhaustive but merely provides examples of separately billable procedures that may be reported in addition to critical care.

  • What is the appropriate use of the -25 modifier when billing for critical care services and separately billable services or procedures?
    Recommendations
    Answer

    CPT does not require the use of the -25 modifier when billing for critical care services and separately billable (i.e. non-bundled) procedures.  However, critical care services provided to a patient may not be paid by some payers (e.g. Medicare) on the same day the physician also bills a non-bundled procedure code(s) unless critical care is billed with the CPT modifier -25 to indicate that the critical care is "a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative care associated with the procedure that was performed”.

    For such payers, when services such as endotracheal intubation (CPT code 31500) and CPR (CPT code 92950) are provided, separate payment may be made for critical care in addition to these services if the critical care was a significant separately identifiable service and it was reported with modifier -25. The time spent performing the pre, intra, and post procedure work of these unbundled services is excluded from the determination of the time spent providing critical care.

    Answer

    CPT does not require the use of the -25 modifier when billing for critical care services and separately billable (i.e. non-bundled) procedures.  However, critical care services provided to a patient may not be paid by some payers (e.g. Medicare) on the same day the physician also bills a non-bundled procedure code(s) unless critical care is billed with the CPT modifier -25 to indicate that the critical care is "a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative care associated with the procedure that was performed”.

    For such payers, when services such as endotracheal intubation (CPT code 31500) and CPR (CPT code 92950) are provided, separate payment may be made for critical care in addition to these services if the critical care was a significant separately identifiable service and it was reported with modifier -25. The time spent performing the pre, intra, and post procedure work of these unbundled services is excluded from the determination of the time spent providing critical care.

  • Can both CPR and critical care be reported for the same patient encounter?

    Recommendations
    Answer

    Yes, as long as the respective requirements for each service are satisfied and evident from the medical record.  Both CPT and Medicare agree on this point.

    CPR (CPT 92950) is a non-E/M service encompassing such activities as performing or supervising chest compressions, adequate ventilation of the patient (e.g., bag-valve-mask), etc.  As a separately reportable service with critical care, the time spent providing CPR cannot be counted toward calculating total critical care time.

    In contrast, critical care is an E/M service encompassing time spent in work directly related to care of the individual patient's critical illness/injury, whether that time was spent at the immediate bedside or elsewhere on the floor or unit.  For example, time spent on the unit or at the nursing station on the floor reviewing test results or imaging studies, discussing the critically ill patient's care with other medical staff or documenting critical care services in the medical record would be reported as critical care, even though it does not occur at the bedside.  Also, when the patient is unable or clinically incompetent to participate in discussions, time spent on the floor or unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient's condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care, provided that the conversation bears directly on the management of the patient.

    Critical care is a time-dependent E/M service.  If the minimum total time requirement is not satisfied and/or documented, then an appropriate other E/M code should be reported.  Of course, any site of service, and key components (i.e., history, physical examination, and medical decision making), etc. criteria for such alternative E/M will have to be satisfied and documented.  Some payers require that a -25 modifier be appended to the critical care E/M or alternative E/M code to indicate that it is a separately identifiable E/M service.

    Answer

    Yes, as long as the respective requirements for each service are satisfied and evident from the medical record.  Both CPT and Medicare agree on this point.

    CPR (CPT 92950) is a non-E/M service encompassing such activities as performing or supervising chest compressions, adequate ventilation of the patient (e.g., bag-valve-mask), etc.  As a separately reportable service with critical care, the time spent providing CPR cannot be counted toward calculating total critical care time.

    In contrast, critical care is an E/M service encompassing time spent in work directly related to care of the individual patient's critical illness/injury, whether that time was spent at the immediate bedside or elsewhere on the floor or unit.  For example, time spent on the unit or at the nursing station on the floor reviewing test results or imaging studies, discussing the critically ill patient's care with other medical staff or documenting critical care services in the medical record would be reported as critical care, even though it does not occur at the bedside.  Also, when the patient is unable or clinically incompetent to participate in discussions, time spent on the floor or unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient's condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care, provided that the conversation bears directly on the management of the patient.

    Critical care is a time-dependent E/M service.  If the minimum total time requirement is not satisfied and/or documented, then an appropriate other E/M code should be reported.  Of course, any site of service, and key components (i.e., history, physical examination, and medical decision making), etc. criteria for such alternative E/M will have to be satisfied and documented.  Some payers require that a -25 modifier be appended to the critical care E/M or alternative E/M code to indicate that it is a separately identifiable E/M service.

  • What are the performance and documentation requirements for use of the critical care service codes with regard to Medicare's split/shared service rules for services involving physicians assistants and nurse practitioners?

    Recommendations
    Answer

    For 2022, CMS released new language for a shared critical care visit between a PA/NP and the emergency physician allowing the total time between the providers to be combined. The provider who furnished the majority of the time is the one who should report the critical care codes.

    Additional References

    Answer

    For 2022, CMS released new language for a shared critical care visit between a PA/NP and the emergency physician allowing the total time between the providers to be combined. The provider who furnished the majority of the time is the one who should report the critical care codes.

    Additional References

Updated December 2021

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.

The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer.

For information about this FAQ/Pearl, or to provide feedback, please contact David A. McKenzie, ACEP Reimbursement Director at (469) 499-0133 or dmckenzie@acep.org.

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