CRITICAL CARE SERVICES (CODES 99291-99292)
A. Use of Critical Care Codes
Pay for services reported with CPT codes 99291 and 99292 when all the criteria for critical care and critical care services are met. Critical care is defined as the direct delivery by a physician(s) 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.
Critical care involves high complexity decision making 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.
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. Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present.
Providing medical care to a critically ill, injured, or post-operative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements.Critical care is usually, but not always, given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit, or the emergency department. However, payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care.
What Qualifies as Critical Care?
The Centers for Medicare & Medicaid Services (CMS) defines criti-cal care services as direct physician care of “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” provided in any location. For Medicare, medical necessity is achieved when both organ or system failure — such as circulatory, respiratory, renal, central nervous system, hepatic, and/or metabolic failure — and a high probability of imminent or life-threatening deterioration are present. For coding purposes, CPT® requires a high complexity of medical decision making (MDM) in addition to reporting critical care.
For example, a patient with a severe case of COVID-19 may pres-ent single or multisystem failure, such as cardiogenic shock and renal failure, but in addition to the system failure, documentation must show a high probability of imminent or life-threatening deterioration in the patient’s condition. If the provider documents that the patient’s condition is stable, has no complaints, was taken off the ventilator and put on room air, or will be discharged tomorrow, there is a low ikelihood that the encounter meets either Medicare’s or CPT®’s definition of critical care services.
Time ConsiderationsEvaluation, care, and management of the patient at the bedside or on the f loor/unit on a per-day basis can be continuous or intermittent. Discussion with other physicians/care team, review of labs and other diagnostic data, dictation, and bundled procedures all count toward total time. (Note: The physician must be immediately available and cannot be overseeing the care of any other patients for the time to count toward the critical care.) Total time also includes time spent with family or decision-makers reporting on the patient’s condition or obtaining a medical history and decision making if the patient is unable to participate. For a patient with COVID-19, once the disease process has become severe enough to require sedation and intubation, decision-making by another responsible source can also be counted toward the time.
However, if the time spent with the patient providing critical care services is less than the defined time for the code, assign only a code for the appropriate evaluation and management (E/M) service. For example, a patient was admitted to the ICU, and the next day, a provider sees the patient who has COVID-19, acute hypoxic respiratory failure, and acute-on-chronic renal failure. The provider documents the critical care interventions taken and the time as 23 minutes. In this case, code assignment should be for subsequent hospital care, not critical care
Chronic Illness and Critical Care:
Examples of patients whose medical condition may not warrant critical care services:
- Daily management of a patient on chronic ventilator therapy does not meet the criteria for critical care unless the critical care is separately identifiable from the chronic long term management of the ventilator dependence.
- Management of dialysis or care related to dialysis for a patient receiving ESRD hemodialysis does not meet the criteria for critical care unless the critical care is separately identifiable from the chronic long term management of the dialysis dependence (refer to Chapter 8, §160.4). When a separately identifiable condition (e.g., management of seizures or pericardial tamponade related to renal failure) is being managed, it may be billed as critical care if critical care requirements are met. Modifier –25 should be appended to the critical care code when applicable in this situation.
Examples of patients whose medical condition may warrant critical care services:
- An 81 year old male patient is admitted to the intensive care unit following abdominal aortic aneurysm resection. Two days after surgery he requires fluids and pressors to maintain adequate perfusion and arterial pressures. He remains ventilator dependent.
- A 67 year old female patient is 3 days status post mitral valve repair. She develops petechiae, hypotension and hypoxia requiring respiratory and circulatory support.
- A 70 year old admitted for right lower lobe pneumococcal pneumonia with a history of COPD becomes hypoxic and hypotensive 2 days after admission.
- A 68 year old admitted for an acute anterior wall myocardial infarction continues to have symptomatic ventricular tachycardia that is marginally responsive to antiarrhythmic therapy
Critical Care Documentation
Critical Condition
**A critical illness or injury acutely impairs one or more vital organ systems.
**High probability of imminent or life-threatening deterioration .
** although critical care may be delivered in a moment of
crisis or upon being called to the patient’s bedside
emergently, this is not a requirement for providing critical
care service. The treatment and management of the
patient’s condition, while not necessarily emergent, shall
be required, based on the threat of imminent
deterioration.
Common Critical Conditions
** Respiratory failure or circulatory failure.
** Organ system which has failed or is failing.
** Significantly abnormal vital signs.
** Shock.
** Acidosis.
** Need for interventions such as central venous access, thoracostomy, transfusion of blood, cardioversion/defibrillation, “ACLS” type IV medications.
** Trauma patients with serious injuries.
** Patients requiring ICU admission.
Time
**The physicians total time spent performing critical care must be clearly documented.
** The time that can be reported as critical care is the time spent engaged in work directly related to the individual patient’s care whether that time was spent at the
immediate bedside or elsewhere on the floor or unit.
** Time involved with family members or other surrogate decision makers may be counted toward critical care time when :
— The patient is unable or incompetent to participate in giving a history and/or making treatment decisions, and
— The discussion is necessary for determining treatment decisions.
** Time spent in activities that occur outside of the ED may not be included because the physician is not immediately available to the patient.
** Also applies if the patient is not immediately available to the physician, i.e. Pt is in another dept or prior to arrival in the ED
** Time counted towards critical care services may be continuous or intermittent and aggregated in time increments
** e.g., 50 minutes of continuous clock time or (5) 10 minute blocks of time spread over a given calendar date
** Per CPT – Time spent performing separately reportable procedures or services should not be included in the time reported as critical care time.
** Per CMS – Time involved performing procedures that are not bundled into critical care (i.e., billed and paid separately) may not be included and counted toward critical care time.
** Per CMS – The physician’s progress note(s) in the medical record should document that time involved in the performance of separately billable procedures was not counted toward critical
care time.
Medical Necessity
Critical care services must be medically necessary and reasonable.
Although critical care may be delivered in a moment of crisis or upon being called to the patient’s bedside emergently, this is not requirement for providing critical care service.
Providing medical care to a critically ill patient should not be automatically deemed as critical care service for the sole reason that the patient is critically ill or injured.
