The Elements of Critical Care

Specific requirements must be met for treatment to be considered critical.

There are two critical care care CPT codes, 99291 and 99292.

99291: 30-74 minutes of critical care provided to a patient on a single date. Reported per date of service.

99292: additional set(s) of 30-minute increments of critical care provided to the patient, if care goes beyond that of the initial 74 minutes. Can be reported more than once for a single date of service.

Specific requirements must be met for treatment to be considered critical. Each of the following measures should be present within the reporting provider’s documentation to prove medical necessity and to uphold as such in the case of a claim’s request for records or claim denial.

As displayed within the definition of CPT 99291, at least 30 minutes must be spent treating the patient face-to-face. An appropriate E/M service should be billed if less than 30 minutes are spent treating the patient. Documentation should include the exact amount of time spent with the patient; stating the range of time will not suffice.

99291 is reported per date of service. This level of critical care can only be billed by one provider within a single date of service. There is an exception. If the second provider is of a different specialty and treating for a distinctly separate injury or illness that also meets the critical care criteria, 99291 can be reported on the same date of service as another provider.

As defined by CMS, a patient is not considered critical unless their “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 treatment of single or multiple vital organ system failure will involve a high, complex level of decision making to evaluate, manipulate and sustain the organ system(s) as well as prevent the further life-threatening deterioration. Both requirements must be met to be considered critical care. Without both, it is not medically necessary to report 99291 or 99292. 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. The documentation should not only report the organ system failure but also the highest specificity of the diagnosis in correlation.

If the treatment provided meets the critical care definition, it can be reported from any place of service. Generally, critical care is provided within an intensive care unit, emergency room, etc. However, there are no limitations as to the place of service critical care can be reported.

In the case that all above criteria are not met, you should report the appropriate E/M code not 99291 or 99292.

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