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Critical Care Billing Guidelines

Critical Care services are provided directly by a physician to patients having injuries which impair one or more vital organ systems in such a way there is a high probability of imminent or life threatening deterioration in the patient’s condition. After a patient receives this urgent medical care, certain criteria must be adhered to for successful Critical Care billing.

Critical Care (CC) Criteria Overview

CC Physician Standards

  • The provider must treat the critical illness using “high complexity decision making to assess, manipulate, and support vital systems to treat single or multiple vital organ system failure and/or prevent further life threatening deterioration of the patient’s condition”
  • The care must be medically necessary in the treatment or management of a patient’s imminent deterioration condition

CC Locations

  • The care requires the personal attention of the provider. Care must be provided at the bedside or on the floor/unit where the patient is housed
  • Critical care is usually provided, but not limited to the following
    • Coronary care unit
    • Intensive care unit
    • Respiratory care unit
    • Emergency Department
  • Note: Medicare payment may be made for any location, as long as the nature of the patient’s condition for care meets the definition of critical care.

CC Time

  • Time spent evaluating, providing care and managing critical care patient
    • Requires full attention from physician
    • NO other services may be provided to any other patient(s) concurrently during same time period
    • Physician must have spent at least 30 minutes providing critical care
    • Once critical care management and time requirements have been met, any additional care time is then divided into blocks
    • Time spent will either be continuous or intermittent, then aggregated and measured from midnight to midnight each day
  • Time based
    • May be continuous, intermittent and aggregated
    • Physicians of same specialty within same group practice may bill and are paid as though they were a single physician
    • Only one physician may bill for critical care during any one single period of time, even if more than one physician is providing care

CC Family Discussions

  • Includes pre and post service work
    • Routine daily updates or reports to family members are considered part of this service
  • Time with family members may be counted towards critical care if:
    • Patient is unable to participate in giving a history or making treatment decisions
    • Discussion is necessary for determining treatment decisions
  • All other family discussions no matter how lengthy may not be counted towards critical care 

Billing for Critical Care

Critical Care Codes 99291 – 99292

  • Time-based service codes provided on an hourly or fraction of an hour basis
  • Time counted towards critical care service may be continuous clock time or intermittent and aggregated in time increment
  • Documentation for each date and encounter must accurately state the appropriateness and include the total time spent providing critical care
  • Services that are separately payable and not bundled into critical care may not be included and counted toward critical care time
  • Critical care cannot be billed if less than 30 minutes was spent in a day by a single provider/or group

Critical Care CPT Code 99291

  • 99291 is reported for the first 30-74 minutes
  • Only once per calendar day per provider/same specialty group
  • Less than 30 minutes should be reported with the appropriate evaluation and management (E/M) codes
  • Each additional 30 minutes beyond the first 74
  • Reportable for the final 15 minutes on any given date
  • Can be aggregated time met by a single physician or same group practice of the same specialty or covering provider.


Separately Billable

  • NO split shared services allowed
  • Medically necessary procedure codes may be billed separately
  • Other procedure codes not bundled into critical care services
  • Separate non critical care E/M codes

Inappropriate Time Counted

  • Procedures not bundled into critical care
  • Time not involved should not be counted towards critical care time
  • Medical records should reflect time involved of the separately billable procedures
  • Teaching sessions with residents – even if bedside


Critical Care and Other E/M Visits

Emergency Room (ER) and Critical Care

  • A patient arrives in the ER in cardiac distress and is treated by the ER physician
  • If an appropriate ER code exists and the standard of care can reasonably be provided within those codes, the 99282- 99285 should be utilized by the ER physician. However, if the nature of the patient’s condition meets the critical care definition then only the critical care code (99291) should be billed, not both
  • A cardiologist is called to the ER and assumes responsibility for the patient, and provides critical care services may also bill a 99291
  • The patient stabilizes and is transferred to the CCU

Hospital Visit and Critical Care Same Day

  • A physician saw an ill patient in the hospital early in the day
  • Later in the afternoon, an NPP from their group performs critical care on the same patient
    • Billing appropriate level E/M under MD’s NPI
    • Billing 99291 with modifier 25 under the NPP’s NPI

Critical Care Global Periods

  • Preoperative critical care may be paid in addition to global fee if:
    • Patient is critically ill and requires full attention of physician
    • Service is unrelated to specific anatomic injury or general surgical procedure performed
      • Modifier 25 with 99291 and/or 99292
  • Postoperative critical care may be paid in addition to global fee if:
    • Documentation supports that critical care was unrelated to specific anatomic surgery performed
      • Modifier 24 with 99291 and/or 99292
  • Time spent performing the pre, intra and/or post procedure work shall be excluded from the time spent providing critical care

Critical Care and Concurrent Care

  • May be paid if:
    • Meets critical care criteria
    • Medically necessary
    • Not duplicative
    • Generally of a different specially
      • Example Cardiologist vs. Endocrinologist


Appropriate Critical Care Documentation includes:

  • The critical and unstable nature of the patient’s condition should be accurately documented to support the medical necessity of the extended 1 to 1 services
  • Complexity of medical decision making
  • Aggregation of time spent by the billing provider if applicable
  • Patient assessment
  • Family discussions – substance of discussion
  • Key Component: Total time spent
  • Note: Documentation must match the complexity of medical decision making as well as the time spent in critical care exclusive of time spent during invasive diagnostic or therapeutic procedures such as intubation, bronchoscopy, cardioversion, tube thoracostomy, or central venous catheter insertion

Common Critical Care Documentation Failures

  • Level of service – Documentation did not support the level of service of Critical Care
  • Signatures – Lacking, illegible, invalid, most notable when the medical record is in the electronic format
  • No medical necessity – Documentation failed to support the medical necessity of the services rendered per the IOM 100-4 CH12 30.6.12 and the E&M Guides
  • Missing or insufficient documentation
  • Total amount of critical care time not documented in the patient’s medical record for each date of service

Does NOT Meet CC Criteria

  • The provision of care to a critically ill patient is not automatically a critical care service just because the patient is critically ill or injured. Services provided do not qualify as CC if:
    • Patient admitted to a critical care unit due to hospital rules regarding certain treatments (e.g. infusions) to be administered in the critical care unit
    • Daily management of patient on ventilator therapy


Source(s): Part B Provider Outreach & Education, “Critical Care Billing and Coding,” Noridian Health Solutions, February 2015