Will Your Critical Care Services Pass An Audit?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Feb 8th, 2022

What Are Critical Care Services

According to Noridian, a Medicare Administrative Contractor (MAC):

CMS defines critical care as “the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient” and also 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.” We have included several examples of critical care situations, provided by CMS.

While this basic definition of critical care services (CCS) is similar in nature to other CMS MACs, commercial payers, and the CPT codebook guidelines, it is important to know the exact billing criteria for each payer. When billing any procedure or service, it is vital that the physician or other QHP has documented the details of the service in a manner that supports medical necessity and the code description. 

Who Qualifies for CC Services? 

Just because a patient is located in a critical or intensive care unit does not mean the service automatically qualifies as critical care. According to Novitas, there are two criteria that must be met in order to report critical care services (99291, 99292) instead of an E/M service:

Clinical condition criterion - There is a high probability of sudden, clinically significant, or life threatening deterioration in the patient’s condition which requires the highest level of physician preparedness to intervene urgently. Treatment criterion - Critical care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or 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.

Patients admitted to the hospital, more often than not, require high complexity decision making. However, patients receiving critical care services are those that are hospitalized and their condition is so complex or risky that they have a high probability of dying without immediate and advanced medical care. Critical care services require the provider be qualified to evaluate and treat for the condition and the ability to intervene immediately. 

Patients who have been admitted to an intensive or critical care unit (ICU/CCU) do not automatically qualify for critical care services (CCS). Each patient encounter must be evaluated to determine whether the patient’s status on that date continues to qualify for CCS or should be reported as subsequent hospital E/M services. As a matter of fact, while most patients receiving critical care services are physically located in the hospital setting, it is also possible for them to receive critical care services in the office, urgent care, ambulatory surgery center (ASC), or elsewhere. There is no “designated room” set aside where critical care services have to  be provided but the criteria must be met for patient qualifications and provider work/documentation.

Who Can Provide Critical Care Services? 

Providers such as MDs, DOs, NPs, PAs, and residents may perform critical care services, if qualified by licensure and scope of practice to do so. While a resident may perform critical care services, they can only be billed IF the attending physician (teaching physician) was present the entire time and only the time spent by the attending physician is counted. No time spent by the resident performing critical care services may be counted for billing purposes.

Critical Care Services are Time-Based

The code description identifies the time requirement for each code: 

Code	Unit	Time
99291	1	30-74 minutes
99292 (+)	1	each additional 30 minutes

The following bullets delineate the specific time-based reporting CPT guidance: 

• Count only the time spent by the physician, NP, or PA performing critical care services. Do not report any nursing or ancillary time, time spent performing separately reportable services, time spent with another patient, or time spent with the family that do not meet the specific exceptions.
• You may count time spent performing services that are bundled into the critical care services, which include: interpretation of cardiac output measurements, chest x-rays (professional component), blood gases, collection/interpretation of physiological data, temporary transcutaneous pacing, ventilator management, and vascular access procedures. 
• Do not count time spent performing services that are separately reportable even when performed as part of the critical care service.
• Resident physicians may perform critical care services but only the time of the attending physician may be counted towards the critical care service. 
• Do not report critical care service codes if the minimum times are not reached for 99291 cumulatively. Instead, report subsequent hospital E/M services (99231-99233). 
• Once a provider reports critical care services for the patient, they may not report any other E/M services for that patient on the same date. The only exception to this is if the provider performed E/M services prior to the patient being placed into critical care. 
• Time is cumulative for providers in the same service (e.g., cardiovascular service, neurology service) on the same calendar day. 
• Multiple providers from multiple specialty services may report critical care services only if the criteria for reporting critical care services has been met by each specialty service. In other words, if the patient is in the ICU and receiving critical care services from the neurology service related to a nervous system failure and the cardiovascular service is also seeing the patient to manage their blood pressure in a noncritical setting, only the Neurology services would be reportable as critical care services. 
• Multiple specialty services may provide critical care services on the same day but time is cumulative for each specialty service (e.g., providers in the Cardiology Service sum their times separately from providers in the Neurology Service). 
• Critical care services cannot be split-shared services. 

Critical Care Coding Scenarios

• Dr. Smith (Neurology Service) provided critical care services to the patient that included 58 minutes at 10 a.m., and another 14 minutes at 3 p.m. Dr. Anders (also from the Neurology Service) came on shift and provided an additional 32 minutes of critical care services to the patient. The total amount of time spent providing critical care services by the Neurology Service on that date was 104 minutes, qualifying for 99291 (74 minutes), and 99292 (30 minutes). 

• Dr. Peterson performs 22 minutes of critical care services including 4 minutes of ECG interpretation, and 11 minutes of ventilator management. The ECG and ventilator management times are bundled services so the time for them may be added to the critical care services time for a total of 37 minutes or 99291. 

Auditing Critical Care Services

Critical care services involve high complexity medical 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. The patient encounter notes must support services that involve high complexity decision making and treatment of a critical condition and should not be supported by cloned, templated, or copied and pasted notes with no updates to show what has changed since the last encounter. 

When reviewing critical care service notes, it is best to disregard cloned or copied/pasted documentation that does not clearly identify applicability to the current encounter. Look for documentation that shows what is new and differs from the last critical care encounter. Patients in critical care who have become stable and will be moved out of critical care are reported with subsequent hospital E/M service codes. Critical care, day after day, should not occur without justification.

About the Author: Aimee 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. She 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.

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.