Understanding the Key Elements of Critical Care Coding

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Original story posted on: July 22, 2019

For some coders, confusion exists when coding for critical care services.

Code 99291 is used for critical care, evaluation, and management of a critically ill or critically injured patient, specifically for the first 30-74 minutes of treatment. It is to be reported only once per day, per physician or group member of the same specialty.

Code +99292 is for critical care, evaluation, and management of a critically ill or critically injured patient, specifically for each additional 30 minutes of treatment. It is to be listed separately, in addition to the code for primary service. Code 99292 is categorized as an add-on code that must be reported on the same invoice as its primary code, 99291. Multiple units of code 99292 can be reported per day, per physician/group; however, there are exceptions to this add-on code.

Despite recent increases in resources and references for critical care billing, critical care reporting issues persist. Medicare data analysis continues to identify 99291 as having high risk for claim payment errors, perpetuating prepayment claim edits for outlier utilization and location discrepancies (i.e., settings other than an inpatient hospital, outpatient hospital, or the emergency department).

Strengthen your documentation with these key elements:

Critical Illness, Injury Management

Current Procedural Terminology (CPT) and the Centers for Medicare & Medicaid Services (CMS) define a “critical illness or injury” as a condition 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 (e.g., central nervous system failure; circulatory failure; shock; renal, hepatic, metabolic, and/or respiratory failure, etc.).

Hospitalists providing care to a critically ill patient must perform highly complex decision-making and interventions of high intensity that are required to prevent the patient’s decline. CMS further elaborates that “the patient shall be critically ill or injured at the time of the physician’s visit.” This is to ensure that hospitalists and other specialists support the medical necessity of the service and do not continue to report critical care codes on days after the patient has become stable and improved.

Consider the following scenarios:

CMS examples of scenarios involving patients whose medical condition may warrant critical care services (99291, 99292) include:

  • An 81-year-old male patient is admitted to the ICU following an abdominal aortic aneurysm resection. Two days after surgery, he requires fluids and pressors to maintain adequate perfusion and arterial pressures. He remains ventilator-dependent. Forty minutes are spent attempting to stabilize the patient.
  • A 67-year-old female patient is three days post-mitral valve repair. She develops hypotension and hypoxia, requiring respiratory and circulatory support. Critical Care time is 40 minutes.
  • A 70-year-old with a history of COPD is admitted for right lower lobe pneumococcal pneumonia and becomes hypoxic and hypotensive two days after admission. A total of 35 minutes is spent in critical care of this patient.
  • 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, and 35 minutes is spent trying to mobilize the patient prior to stent placement.

CMS examples of patients who may not satisfy Medicare medical necessity criteria, do not meet critical care criteria, or do not have a critical care illness or injury (and, therefore, are not eligible for critical care payment, but may be reported using another appropriate hospital care code, such as subsequent hospital care codes, 99231-99233, or initial hospital care codes, 99221-99223) include the following:

  • Patients admitted to a critical care unit because no other hospital beds were available;
  • Patients admitted to a critical care unit for close nursing observation and/or frequent monitoring of vital signs (e.g., due to drug toxicity or overdose);
  • Patients admitted to a critical care unit because hospital rules require certain treatments (e.g., insulin infusions) to be administered in the critical care unit; and
  • Patients receiving only care of chronic illness in the absence of care for critical illness (e.g., daily management of a chronic ventilator patient, management of or care related to dialysis for end-stage renal disease, etc.). Such services are considered palliative in nature, as this type of care does not meet the definition of critical care services, because the patients are otherwise stable at the physician encounter.

Concurrent Care

Critically ill patients often require the care of hospitalists and other specialists throughout the course of their treatment. Payors are sensitive to multiple hours billed by multiple providers for a single patient on a given day. Claim logic provides an automated response to only allow reimbursement for 99291 once per day, when reported by physicians of the same group and specialty. Physicians of different specialties can separately report critical care hours as long as they are caring for a condition that meets the definition of critical care.

  • The CMS example of this: a dermatologist evaluates and treats a rash on an ICU patient who is maintained on a ventilator, with nitroglycerine infusion managed by an intensivist. The dermatologist should not report a service for critical care.
  • Similarly, for hospitalists, if an intensivist is taking care of the critical condition and there is nothing more for the hospitalist to add to the plan of care for the critical condition, critical care services may not be justified.
  • When different specialists are reporting critical care on the same day, it is imperative for the documentation to demonstrate that one provider’s care is not duplicative of any other provider’s care (i.e., identify management of different conditions or revisions to elements of the plan). The care cannot overlap with the same time period of any other physician reporting critical care services.

Calculating Time

Critical care time constitutes bedside time and time spent on the patient’s unit/floor, where the physician is immediately available to the patient (see table below). Certain labs, diagnostic studies, and procedures are considered inherent to critical care services and are not reported separately on the claim form: cardiac output measurements (93561, 93562), chest X-rays (71010, 71015, 71020), pulse oximetry (94760, 94761, 94762), and blood gases. The CPT Book has a complete list.

Total Duration of Critical Care       Codes
_______________________________________
Less than 30 minutes                     Approx. E&M
(less than 1/2 hours)                      codes
_____________________________________
30-74 minutes                                  99291 X 1
(30 min-1 hr 14 min)                     
_______________________________________
75-104 minutes                                99291 X 1 &
(1 hr 15 min - 1 hr 44 min)            99292 X 1
_______________________________________
105-134 minutes                             99291 X 1 &
(1 hr 45 min - 2 hr 14 min)            99292 X 2
_______________________________________
135-164 minutes                             99291 X 1 &
(2 hr 15 min - 2 hr 44 min)            99292 X 3
_______________________________________


  • When separately billable procedures are performed by the same provider/specialty group on the same day as critical care, physicians should make a notation in the medical record indicating the non-overlapping service times (e.g., “central line insertion is not included as critical care time.”). This may assist with securing reimbursement when the payor requests the documentation for each reported claim item.
  • Activities on the floor/unit that do not directly contribute to patient care or management (e.g., review of literature, teaching rounds) cannot be counted toward critical care time. Do not count time associated with indirect care provided outside of the patient’s unit/floor (e.g., reviewing data or calling the family from the office) toward critical care time.
  • Instead, physician time associated with the performance and/or interpretation of these services is counted toward the cumulative critical care time of the day. Services or procedures that are considered separately billable (e.g., central line placement, intubation, CPR) cannot contribute to critical care time.
  • Family discussions can be counted toward critical care time, but must take place at the bedside or on the patient’s unit/floor. The patient must participate in the discussion unless medically unable or clinically incompetent to participate. If unable to participate, a notation in the chart must delineate as such, and the reason.
  • Credited time can only involve obtaining a medical history and/or discussing treatment options or limitation(s) of treatment. The conversation must bear directly on patient management.
  • Do not count time associated with providing periodic condition updates to the family, answering questions about the patient’s condition that are unrelated to decision-making, or counseling the family during a grieving process. If the conversation must take place via phone, it may be counted toward critical care time if the physician is calling from the patient’s unit/floor or bedside and the conversation involves the same criterion identified for face-to-face family meetings, but the documentation in the record must reflect the reason the family could not be present – and be aware, some payors will not allow it.
  • Physicians should keep track of their critical care time throughout the day. Since critical care time is a cumulative service, each entry should include the total time that critical care services were provided (e.g., 45 minutes). Some payors may still impose the notation of “start-and-stop time” per encounter (e.g., 1-1:50 a.m.).
  • Same-specialty physicians (i.e., two hospitalists from the same group practice) may require separate claims. The initial critical care hour (99291) must be logged by a single physician. Medically necessary critical care time beyond the first hour (99292) may be met individually by the same physician or collectively with another physician from the same group. The physician performing the additional time beyond the first hour reports the appropriate units of 99292 under the corresponding NPI. It’s the only add-on code in CPT that is allowed to be billed alone to Medicare, without a base code first.
  • CMS has issued instructions for contractors to recognize this atypical reporting method. However, non-Medicare payors may not recognize this newer reporting method and maintain that the cumulative service (by the same-specialty physician, in the same provider group) should be reported under one physician name. Be sure to query the payors for appropriate reporting methods. 

Programming Note:

Listen to Terry Fletcher report this story live today during Talk Ten Tuesday, 10-10:30 a.m. EST.

Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS,  ACS-CA, SCP-CA, QMGC, QMCRC

Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC, is a healthcare coding consultant, educator, and auditor with more than 30 years of experience. Terry is a past member of the national advisory board for AAPC, past chair of the AAPCCA, and an AAPC national and regional conference educator. Terry is the author of several coding and reimbursement publications, as well as a practice auditor for multiple specialty practices around the country. Her coding and reimbursement specialties include cardiology, peripheral cardiology, gastroenterology, E&M auditing, orthopedics, general surgery, neurology, interventional radiology, and telehealth/telemedicine. Terry is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.

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