Coding Critical Care Services in 2023

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Aug 3rd, 2023

Critical care services refer to the delivery of medical care to the critically ill or injured patient by a qualified physician or other qualified healthcare professional (QHP). Current Procedural Terminology (CPT) defines a critical illness or injury as one 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.” Centers for Medicare and Medicaid Services (CMS) defines critical illnesses or injuries as “those with acute impairment to one or more vital organ systems with an increased risk of imminent or life-threatening health deterioration.”

These definitions basically say the same thing, which is that the patient record must reflect the following, answered with two questions: 

1. What is the patient’s acute impairment to one or more vital organ systems?
2. What about the patient’s critical illness or injury indicates an increased risk or high probability of imminent or life-threatening deterioration?

Critical care involves a high-level of critical thinking and decision making in order to evaluate, assess, manipulate, and/or support the patient’s vital system functionality and to prevent additional deterioration, loss of functionality, or death. Vital organs are those that are imperative for life functions (e.g., heart, lungs, brain, kidneys, liver) and impairment may include anything from dysfunction to complete organ failure, as well as sepsis and shock.

Critical care services are often provided in the critical care unit (CCU) or intensive care unit (ICU), but may be performed in any area of the hospital where deemed necessary. Often critical care services include ordering and interpretation of many physiological tests or the use of advanced life-saving technologies (e.g., ventilator, CPR). 

Services and Procedures Included in the Critical Care Services (99291, +99292)

Some services are naturally part of the critical care services provided by physicians/QHPs and should not be separately reported. Any services performed outside of the following should be separately reported, but these are considered bundled into the critical care service codes (99291, +99292): 

• Interpretation of cardiac output measurements (93598)
• Chest x-rays (71045, 71046)
• Pulse oximetry (94760, 94761, 94762)
• Blood gases
• Collection and interpretation of physiologic data, including ECG, blood pressures, hematologic data, etc.
• Gastric intubation (43752)
• Temporary transcutaneous pacing (92953)
• Ventilatory management services (94002-94004, 94660, 94662)
• Vascular access procedures (36000, 36410, 36415, 36591, 36600)

Critical Care Services are Time-Based Codes

As with all time-based services, the provider must document the total time spent in the work that is directly related to the individual patient’s care, either at the immediate bedside or on the floor, or unit, such as at the nursing station performing patient-specific tasks like reviewing test and imaging results, discussing the diagnosis and treatment options with other healthcare professionals, or documenting critical care services in the patient’s medical record. 

Time does not have to be continuous to be reported. Multiple providers within the same group, specialty and subspecialty often perform critical care services at different times during the same calendar date and sum those times together to determine if the time requirements have been met for reporting 99291 and +99292 with added units. 

Time is counted by minutes with 99291 reported once 30 minutes has been spent performing critical care services on a given calendar date. If less than 30 minutes is spent providing critical care services, an Evaluation & Management (E/M) code should be reported instead, from the appropriate E/M category for where the services occurred. Code 99292 is an add-on code, indicating more than 30 minutes of time was spent, represented by the plus symbol (+) before the code. This means that 99292 cannot be reported if a primary code (99291) has not been reported for that date of service. 

Providers in the same group, specialty, and subspecialty sum their time spent providing critical care services to the same patient on the same date and then determine the correct code application. Providers of different specialties may report critical care services independent of each other, especially if the patient has more than one critical illness requiring the attention of more than one type of specialist. 

CPT and Medicare Have Different Requirements for +99292

While the CPT Guidelines include a table that shows the recommended critical care service codes based on total minutes documented, the times associated with 99292 do match with the CMS guidelines for reporting critical care services. 

CPT allows you to report one unit of 99291 when 30-74 minutes have been documented and once the provider reaches 75 minutes, they may report +99292 also. However, Medicare has clarified in this document a requirement of 104 minutes be completed before one unit of +99292 may be reported. We recommend you verify this with your Medicare Administrative Contractor to ensure proper coding and reduce the possibility of denials or overpayments that may result in refund demands in an audit performed at a later date. 

Coding Considerations for Critical Care Services 

• Only report one unit of 99291 and remember additional qualifying time is reported with add-on code +99292 and not additional units of 99291
• Do not count towards critical care services any time spent outside of the patient’s floor/unit, even if they are directly related to the patient’s care, as the requirement is that the physician/NPP be immediately available to the patient
• Do not count time spent performing separately reportable services
• Do not report 99292 without 99291 being reported as the primary code
• Do not count the time of multiple providers when they are jointly meeting with the patient, instead report the time of just one of the providers
• Sum together all time spent by providers of the same group, specialty, and subspecialty performing E/M services to determine the overall E/M service level
• Report modifier FT for critical care services that are unrelated to a procedure

Reporting Critical Care and E/M Services on the Same Date

The E/M visit must be provided before the critical care services and during a time when the patient did not require critical care services, in order to report E/M and critical care services on the same calendar date. The documentation must also make clear the services were medically necessary and are not duplicitous. When reported together, be sure to append modifier 25 to the critical care services in this instance. 

Split or Shared Critical Care Services

As time-based codes, split or shared services sum the total time of each provider in the same group, specialty, or subspecialty performed on the same calendar date to determine the codes and units reported. Once summed and coding determined, the provider who performed the substantive portion of the cumulative critical care time will report the critical care services under their provider number. The substantive portion is defined as the provider who spent more than half of the total time summed between physician and non-physician practitioner (NPP).

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.