Critical Care Billing and Coding – Guidelines to Avoid Denials

by | Last updated Dec 30, 2022 | Published on Mar 2, 2017 | Resources, Medical Coding News (A) | 0 comments

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Many critical care services cannot be billed separately, but the time spent on providing these services counts when it comes to payment. Today, most physicians rely on medical billing companies to simplify the complex process of critical care medical billing.


The CPT definition of critical care service is: the direct delivery by a physician(s) medical care for a critically ill or other qualified health care professional of medical care for a critically injured patient. When providing critical care services, the physician/health care professional has to make high complexity decisions 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.

The definition of critical care by the Centers for Medicare & Medicaid Services (CMS) goes beyond that of CPT. According to CMS, “critical care services must be reasonable and medically necessary … delivering critical care in a moment of crisis, or upon being called to the patient’s bedside emergently, is not the only requirement for providing critical care service. Treatment and management of a patient’s condition, in the threat of imminent deterioration; while not necessarily emergent, is required.”

Key Aspects of Critical Care Services (CPT codes 99291 and 99292)

  • The provider must spend at least 30 minutes providing critical care.
  • Any additional care time is divided into blocks.
  • Time spent may be either continuous or intermittent, then aggregated and measured from midnight to midnight each day.
  • The care requires the personal attention of the provider. Care must be provided at the bedside or on the floor/unit where the patient is housed.
  • Critical care is usually but not limited to areas as: coronary care unit, intensive care unit, respiratory care unit, and emergency department

Critical Care Billing Codes

CPT codes 99291 and 99292 are time-based service codes provided on an hourly or fraction of an hour basis. These codes represent 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.

  • 99291 is used to report the first 30-74 minutes of critical care
    • Only once per calendar day per provider/same specialty group
  • 99292 is an add-on code and used to report additional block(s) of time up to 30 minutes each beyond the first 74 minutes of critical care
    • Reportable for the final 15 minutes on any given date
    • Can be aggregated time met by a single physician or same group practice of the same specialty or covering provider

Critical care time less than 30 minutes should be reported using the appropriate E/M code and not the critical care codes. Time duration (in units) is as follows:

  • Less than 30 minutes – 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
  • 194 minutes or longer – 99291 and 99292 as appropriate

Note: If the critical care service extends into another calendar day at which time continuous critical care services are interrupted, 99291 can be reported for Day 1, and a second 99291 reported for Day 2.

Documentation for each date and encounter must correctly report the appropriateness and include the total time spent providing critical care.

Bundled Services

Both CPT and CMS bundle several services in critical care time when performed during the critical period by the same physician(s) providing critical care:

  • 93561, 93562 Interpretation of cardiac output measurements
  • 71010, 71015, 71020 Chest x-rays, professional component
  • 36415 Blood draw for specimen
  • 99090 Blood gases, and information data stored in computers – e.g., ECGs, blood pressures, hematologic data – CPT 99090
  • 43752, 91105 Gastric intubation
  • 94760, 94761, 94762 Pulse oximetry
  • 92953 Temporary transcutaneous pacing
  • 94002 – 94004, 94660, 94662 Ventilator management
  • 36000, 36410, 36415, 36591, 36600 Vascular access procedures

Unlike CPT, however, for Medicare, the relevant time frame for bundling pertains to the entire calendar day for which critical care is reported, and the time frame is not limited to just the period of time that the patient is critically ill or injured during that calendar day.

Critical Care Global Periods

The global surgical package includes all necessary services normally furnished by a surgeon before, during, and after a procedure. Critical care services billed during a global period are typically those related to the surgical procedure.

Preoperative critical care may be paid in addition to global fee if…

– The patient is critically ill and requires full attention of physician
– Service is unrelated to specific anatomic injury or general surgical procedure performed

  • Modifier 25 should be reported with 99291and/or 99292

Postoperative critical care may be paid in addition to global fee if…

– Documentation supports that critical care was unrelated to specific anatomic surgery performed

  • Modifier 24 should be reported with 99291 and/or 99292

Reliable medical billing companies help physicians navigate these complex critical care documentation and billing guidelines. Such support is crucial when it comes to getting paid for high-value critical care work. Mistakes can be very costly and the services provided by a professional critical care medical billing service provider can prove invaluable to improve billing and coding processes and prevent denials.

Outsource Strategies International.

Being an experienced medical billing and coding company in the U.S., OSI is dedicated to staying abreast of the latest industry guidelines. Our services provide comprehensive support for the success of your practice.

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