Critical care medicine, also known as intensive care medicine, focuses on the specialized care of patients who are at risk of conditions that may be life-threatening and require comprehensive care and constant monitoring. The common conditions that require critical care are heart problems, lung problems, organ failure, brain trauma, sepsis, drug-resistant infections, and serious injury. With an ever-increasing volume of patients, rising acuity levels, and combinations of complex conditions, critical care professionals need to ensure quick response to critical situations. They also need to be knowledgeable about critical care medical billing codes, the rules for reporting critical care, and how to document their services correctly.
CPT Codes and Criteria to Report Critical Care Services
The American College of Emergency Physicians defines critical care services 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”.
There are two CPT codes to report critical care for adult patients:
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 critically injured patient; each additional 30 minutes (List separately in addition to code for primary service)
Though 99292 is an add-on code, reporting of 99292 for critical care does not require the reporting of 99291 for payment.
According to CPT, services billed using these codes need to meet the following conditions:
“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 function(s) to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition.”
To report critical care, it is not necessary that the patient is in the intensive care unit (ICU). Further, not all patients in the ICU may meet the required criteria.
CMS requires that for Medicare patients:
- Critical care services provided must be medically necessary and reasonable and that the critically ill or injured patient must meet the above criteria
- 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
Role of “time”
Time plays a key role in reporting critical care services for both CPT and Medicare. The physician should correctly document the duration of critical care services, which includes:
- time spent evaluating, managing, and providing care, and
- time spent in documenting such activities
The following table shows the use of CPT codes 99291 and 99292 to report the total duration of time spent by a physician providing critical care services:
Source: The American Society of Anesthesiologists.
CPT code 99291 represents the first 30-74 minutes of critical care on a given date and should be used only once on that 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.
One key consideration when determining accrued total time is that the physician should be immediately available to the patient, whether at the patient’s immediate bedside or elsewhere. Other criteria when using CPT codes 99291 and 99292 are:
- Physician time dedicated to the patient can include time spent with the patient’s family or caregivers if the patient cannot participate in the discussions about the care.
- Time spent on activities that do not contribute directly to the critical care should not be counted when calculating critical care time.
- The duration of time spent providing critical care services to a patient on a certain date does not have to be continuous time. Non-continuous time for critical care services may be combined for a single date.
- Time spent on any separately reportable activity should not be counted in critical care time.
- The time spent should be clearly documented in the patient record.
There are also CPT guidelines on how to code critical care services that extend to another calendar day: “…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. If the service is disrupted (i.e., becomes non-continuous), then it creates the need for a new initial service on the post-midnight date” (www.acep.org).
Services included in CPT Codes 99291 and +99292
When billing critical care, physicians need to note that services included CPT codes 99291 and +99292 should not be separately billed. These procedures and their CPT codes as listed by The American Society of Anesthesiologists are as follows:
36000 Introduction of needle or intracatheter, vein
36410 Venipuncture, age 3 years or older, necessitating the skill of a physician or other
qualified health care professional (separate procedure), for diagnostic or therapeutic
purposes (not to be used for routine venipuncture)
36415 Collection of venous blood by venipuncture
36591 Collection of blood specimen from a completely implantable venous access device
36600 Arterial puncture, withdrawal of blood for diagnosis
43752 Naso- or oro-gastric tube placement, requiring physician’s skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report)
43753 Gastric intubation and aspiration(s) therapeutic, necessitating physician’s skill (eg, for gastrointestinal hemorrhage), including lavage if performed
71045 Radiologic examination, chest; single view
71046 Radiologic examination, chest; 2 views
92953 Temporary transcutaneous pacing
93561 Indicator dilution studies such as dye or thermodilution, including arterial and/or venous catheterization; with cardiac output measurement (separate procedure)
93562 Indicator dilution studies such as dye or thermodilution, including arterial and/or venous catheterization; subsequent measurement of cardiac output
94002 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day
94003 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day
94004 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; nursing facility, per day
94660 Continuous positive airway pressure ventilation (CPAP), initiation and management
94662 Continuous negative pressure ventilation (CNP), initiation and management
94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination
94761 Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (eg, during exercise)
94762 Noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring (separate procedure)
Separately billable procedures
Several medically necessary procedure codes may be billed in addition to critical care services. Here are 5 examples:
92950 CPR (while being performed)
31500 Endotracheal intubation (31500)
36555, 36556 Central line placement
33210 Temporary transvenous pacemaker
93010 Electrocardiogram – routine ECG with at least 12 leads; interpretation and report only
When 92950 (CPR) and 31500 (endotracheal intubation) are reported, some payers will make separate payment for critical care if -25 modifier is appended to show that critical care is “a significant, separately identifiable E/M service above and beyond the other service provided”.
With many rules and payer requirements specific to reporting critical care, ensuring accuracy in medical billing can be a challenge. Relying on outsourced medical billing and coding services is best option to ensure error-free claim submission and optimal reimbursement.