By: Sheila Haynes, CPC
Coding and Compliance Manager

Guidelines for Use of Critical Care Codes (CPT codes 99291 and 99292)

To reliably and consistently determine that critical care services, rather than other evaluation and management (E/M) services, are medically necessary the following review criteria must be met in addition to the Current CPT Manual definitions:

Clinical condition criteria

  • 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 criteria

  • Critical care services require direct personal management by the physician, or other qualified healthcare professional.
  • Life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician or other qualified healthcare professional
  • 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.

Providing medical care to a critically ill patient, or a patient in ICU, should not automatically be classified as a critical care service. Conversely, the patient does not have to be in a critical care or intensive care unit to report critical care services as long as the care rendered meets the clinical requirements and definition. The provider’s service must be medically necessary and meet the CPT definition of critical care services as described below in order to be considered covered.

Critical Care Definition – Critical care is the direct delivery by a physician or other qualified healthcare professional of medical care for a critically ill or injured patient.

  • Critical illnesses or injuries are defined as those with impairment to one or more vital organ systems with an increased risk of rapid or imminent health deterioration
  • Critical care services require direct patient/provider involvement with highly complex decision-making in order to evaluate, control, and support vital system functions to treat one or more vital organ system failures and/or to avoid further decline of the patient’s condition.
  • Vital organ system failure includes, but is not limited to, failure of the central nervous, circulatory, or respiratory systems; kidneys; liver; shock; metabolic or respiratory failure, post-operative complications, or overwhelming infection
  • Generally, critical care services necessitate the interpretation of many physiologic parameters and/or other applications of advanced technology as available in a critical care unit, pediatric intensive care unit, respiratory care unit, in an emergency facility, patient room or other hospital department; however, in emergent situations, critical care may be provided where these elements are not available
  • Care provided to patients residing in a critical care unit but not fitting the criteria for critical care is reported using other E/M codes, as appropriate.
  • These are time-based codes, meaning the total time spent must be documented which includes: Direct patient care bedside or time spent on the patient’s floor or unit (reviewing laboratory results or imaging studies and discussing the patient’s care with medical staff, time spent with family members, caregivers, or other surrogate decision makers to gather information on the patient’s medical history, reviewing the patient’s condition or prognosis, and discussing various treatment options or limitations of treatment), as long as the clinician is immediately available and not providing services to any other patient during the same time period.
  • Time spent outside of the patient’s unit or floor, including telephone calls, caregiver discussions, or time spent in actions that do not directly contribute to the patient’s care rendered in the critical unit are not reported as critical care.

Reporting of Provider’s Time Spent in Critical Care Service

Since critical care is a time-based code, the physician’s progress note must contain documentation of the total time involved providing critical care services.

  • Critical care codes are used to report the total duration of time spent by a provider providing critical care services to a critically ill or critically injured patient, even if the time spent by the provider on that date is not continuous.
  • 99291 (evaluation and management of the critically ill or critically injured patient, first 30-74 minutes)
  • +99292 (critical care, each additional 30 minutes)
  • For any given period of time spent providing critical care services, the provider must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.
  • The time involved in performing procedures that are not bundled into critical care (i.e., billed separately) may not be included and counted toward critical care time.
  • The provider’s progress note must document that time involved in the performance of separately billable procedures was not counted toward critical care time.

Time involved with family members or other surrogate decision-makers, whether to obtain a history or to discuss treatment options may be counted toward critical care time only when:

  • The patient is unable or incompetent to participate in giving a history and/or making treatment decisions,
  • The discussion is absolutely necessary for treatment decisions under consideration that day, and

All of the following are documented in the provider’s progress note for that day:

  • The patient was unable or incompetent to participate in giving history and/or making treatment decisions, as appropriate,
  • The necessity of the discussion (e.g., no other source was available to obtain a history” or “because the patient was deteriorating so rapidly needed to discuss treatment options with family immediately”),
  • The treatment decisions for which the discussion was needed, and
  • The substance of the discussion as related to the treatment decision.

The physician’s progress note must link the family discussion to a specific treatment issue and explain why the discussion was necessary on that day. All other family discussions, no matter how lengthy, may not be counted towards critical care time.