Basics of Critical Care 99291 & 99292 CPT code
Critical care is defined as a physician’s (or physicians’) direct delivery of medical care for a critically ill or critically injured patient. 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. 99291 & 99292 CPT code are use for Critical care.
“A critical illness or injury acutely impairs one or more vital organ systems such that the patient’s survival is jeopardized“
Critical care services are used to treat single or multiple vital organ system failure to prevent further life threatening deterioration of the patient’s condition. There are many examples for vital organ system failure which include respiratory failure, renal failure, circulatory failure, central nervous system failure etc. Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patient’s condition continues to require the level of attention described above.
Critical care is usually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or the emergency care facility.
Critical care and other E/M services may be provided to the same patient on the same date by the same individual.
Read also: When to use E/M modifiers 25 and 27 in Medical coding
Services included with Critical Care CPT codes 99291 & 99292
For reporting by professionals, the following services are included in critical care when performed during the critical period by the physician(s) providing critical care:
the interpretation of cardiac output measurements (93561, 93562),
pulse oximetry (94760, 94761, 94762),
blood gases;
gastric intubation (43752, 43753);
temporary transcutaneous pacing (92953);
ventilatory management (94002-94004, 94660, 94662);
and vascular access procedures (36000, 36410, 36415, 36591, 36600).
Any services performed that are not included in this listing should be reported separately. Facilities may report the above services separately.
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Coding as per Critical Care time or duration
Critical care is a time- based service. Payment for critical care services is not restricted to a fixed number of hours, days, or physicians (on a per-patient basis) when such services meet medical necessity; and time counted toward critical care services may be continuous clock time or intermittent in aggregated time increments (e.g. 50 minutes of continuous clock time or five ten minute blocks of time spread over a given calendar date).
Critical care time is “time spent engaged in work directly related to the individual patient’s care,” whether that time is spent at the immediate bedside or elsewhere on the floor or unit. These criteria assume the physician takes an ongoing and active role in managing that patient’s care. Evidence that the above criteria were met must be present in the medical record with the physician’s attestation that critical care was provided.
CPT Codes 99291, 99292 are used to report the total duration of time spent in provision of critical care services to a critically ill or critically injured patient, even if the time spent providing care on that date is not continuous. For any given period of time spent providing critical care services, the individual 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.
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 even if the time spent by the individual is not continuous on that date. Critical care of less than 30 minutes total duration on a given date should be reported with the appropriate E/M code.
Code 99292 is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes. (See the following table.)
The following examples illustrate the correct reporting of critical care services:
Total Duration of Critical Care Codes
less than 30 minutes -> appropriate E/M codes
30 – 74 minutes
(30 minutes – 1 hr. 14 min.) -> 99291 X 1
75 – 104 minutes
(1 hr. 15 min. – 1 hr. 44 min.) -> 99291 X 1 and 99292 X 1
105 – 134 minutes
(1 hr. 45 min. – 2 hr. 14 min.) -> 99291 X 1 and 99292 X 2
135 – 164 minutes
(2 hr. 15 min. – 2 hr. 44 min.) -> 99291 X 1 and 99292 X 3
165 – 194 minutes
(2 hr. 45 min. – 3 hr. 14 min.) -> 99291 X 1 and 99292 X 4
195 minutes or longer
(3 hr. 15 min. or etc.) -> 99291 and 99292 as appropriate (see illustrated reporting examples above)
99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes
+99292 Critical Care, Evaluation & Management, Add’l 30 Min
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Do and Don’t with CPT code 99291 and 99292
Do not code the included services (as mentioned above) with Critical Care CPT codes 99291 and 99292
If separately identifiable procedure has been performed in addition to the evaluation and management (E/M) services on the same calendar day, the modifier 25 should be appended (e.g., 99291-25). The medical records must contain separate documentation for E/M services and the procedure(s). Additionally, a statement should clearly note that the time utilized for billing for the E/M visit does not have overlap with the procedure time.
There are certain situations that call for critical care services to be performed for the same patient on the same day by multiple individuals. Codes 99468, 99469, 99471, and 99472, may be used to report the services required to direct the inpatient care of a critically ill neonate or infant 28 days of age or younger.
They represent care starting with the date of admission (99468) for critical care services and all subsequent day(s) (99469) that the neonate remains in critical care. They may only be reported by a single individual and only once per calendar day per patient.
Time-based critical care services (99291, 99292) are not reportable by the same individual or different individual of the same specialty and same group; however, neonatal or pediatric critical care services (99468-99476) may be reported for the same patient on the same day. In addition, time-based critical care services (99291, 99292) may be reported by an individual of a different specialty from either the same or different group on the same day that neonatal or pediatric critical care services are reported.