Critical Care Services – Critical care is defined as the direct delivery by a physician(s) of 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. 

NPP’s – Nurse Practitioners and Physician Assistants are often referred to as Non Physician Practitioners

STANDARD

Critical Care Services (codes 99291 and 99292) are time-based (i.e., codes are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient) even if the time spent is not on a continuous basis. Critical care services include the patient who is critically ill (i.e. an illness or injury impairs one or more vital organ systems such that the patient’s survival is jeopardized) and has a high risk of mortality or morbidity, even though their vital signs are stable.

Inpatient critical care services provided to:

• neonates (28 days of age or younger) should be reported using codes 99468-99469
• infants 29 days through 24 months of age should be reported using codes 99471-99472.
• infants or young children, 2-5 years of age should be reported using codes 99475-99476

For other inpatient critical care services, code 99291 to report the first 30 to 74 minutes of critical care on a given date. It should be used only once per date even if the time spent by the physician is not continuous on that date. There must be one physician or qualified non-physician practitioner (NPP) who meets the first hour independently for the initial reporting of critical care services with 99291.  Critical care of less than 30 minutes total duration on a given date should be reported with the appropriate E&M code, if appropriate.

Code 99292 is used to report each additional 30 minutes beyond the first 74 minutes. It may also be used to report the final 15-30 minutes of critical care on a given date. Critical care of less than 15 minutes beyond the first 74 minutes or less than 15 minutes beyond the final 30 minutes is not reported separately.

Calculating Critical Care Time:

Critical care time consists of services performed personally by the attending physician; services performed by a resident or other health care provider cannot be included in calculation of critical care time. Time is calculated based on 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.

Activities other than at the immediate bedside that should be included in critical care time include the following (so long as they are performed on the critical care unit): reviewing test results or imaging studies, discussing the patient’s care with other medical staff, documenting critical care services in the medical record or interfacing with family/surrogate decision makers on obtaining information that bears directly on medical decision making. Activities that would not be included in critical care time include telephone calls outside of the unit or floor (i.e. call received at home or in the office are not included since the physician is not immediately available to the patient) or participation in administrative meetings held in the critical care unit.

Critical care time is the cumulative number of minutes/hours spent on care of an individual patient during the course of one day. Total duration of time spent by the physician (even if the time spent is not continuous) should be documented and reported.

Total Duration of Critical Care	CPT Codes
Total Duration of Critical Care Codes Less than 30 minutes	99232 or 99233 or other appropriate E/M code
30 – 74 minutes	99291 x 1
75 – 104 minutes	99291 x 1 and 99292 x 1
105 – 134 minutes	99291 x1 and 99292 x 2
135 – 164 minutes	99291 x 1 and 99292 x 3
165 – 194 minutes	99291 x 1 and 99292 x 4
194 minutes or longer	99291 – 99292 as appropriate (per the above illustrations

Critical Care Services require three (3) criteria:

1. Occurrence of a critical illness or injury that acutely impairs one or more vital organ systems such that the patient’s survival is jeopardized. Services may include: treatment or prevention of further deterioration of central nervous system failure, circulatory failure, shock-like conditions, renal hepatic, metabolic or respiratory failure, postoperative complications or overwhelming infection;
2. The need for direct delivery by a physician of medical care for a critically ill or injured patient; and
3. The provision of bundled services based upon the time the physician spends in furnishing medical care to the critically ill or injured patient.

The following services are included in reporting critical care services:

• Interpretation of cardiac output measurements (93561, 93562);
• Chest X-rays (71010, 71015, 71020);
• Pulse Oximetry (94760-94762)
• Blood draw for specimen (CPT 36415);
• Blood gases and information data stored in computers (e.g. ECGs, blood pressures, hematologic data) (99090);
• Gastric intubation (91105);
• Temporary transcutaneous pacing (92953);
• Ventilator management (94002-94004, 94660, 94662); and
• Vascular access procedures (36000, 36410, 36415, 36591, 36600).

Any services performed that are not listed above should be reported separately.

Critical care is usually, but not always, confined to the hospital’s critical care unit, such as the coronary care unit, intensive care unit, respiratory care, or emergency care units. Critical care codes can also apply to the neonatal intensive care units. 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.

For any given period of time spent providing critical care services the physician must devote his or her full attention to the patient; therefore, cannot provide services to any other patient during the same period of time.

Care need not be time spent immediately at the bedside, but is time that is 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.

Critical Care Services and Qualified Non-Physician Practitioners (NPP)

Critical care services may be provided by qualified NPPs and reported for payment under the NPP’s National Provider Identifier (NPI) when the services meet the definition and requirements of critical care services. The provision of critical care services must be within the scope of practice and licensure requirements for the State in which the qualified NPP practices and provides the service(s). Collaboration, physician supervision and billing requirements must also be met. A physician assistant shall meet the general physician supervision requirements.  Critical care cannot be a shared/split service between a physician and a NPP.  Please see Standard B-411, NP and PA Billing Rules.

Critical Care Services and Other Evaluation and Management Services Provided on Same Day

When critical care services are required upon the patient’s presentation to the hospital emergency department, only critical care codes 99291 – 99292 may be reported. An emergency department visit code may not also be reported.

When critical care services are provided on a date where an inpatient hospital, hospital emergency department, or office/outpatient evaluation and management service was furnished earlier on the same date at which time the patient did not require critical care, both the critical care and the previous evaluation and management service may be paid.

Physicians are advised to submit documentation to support a claim when critical care is additionally reported on the same calendar date as when other evaluation and management services are provided to a patient by the same physician or physicians of the same specialty in a group practice.

Critical Care Services Provided by Physicians in Group Practice(s)

Medically necessary critical care services provided on the same calendar date to the same patient by physicians representing different medical specialties that are not duplicative services are payable. The medical specialists may be from the same group practice or from different group practices.

Critically ill or critically injured patients may require the care of more than one physician medical specialty. Concurrent critical care services provided by each physician must be medically necessary and not provided during the same instance of time. Medical record documentation must support the critical care services provided by each physician were necessary to treat and manage the critical illness (es) or critical injury (ies) of the patient.  Each physician must accurately report the service(s) he/she provided to the patient in accordance with any applicable global surgery rules or concurrent care rules. (Refer to the Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, §40, and the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, §30.)

REGULATORY REFERENCES

Medicare Claims Processing Manual, Ch. 12, 30.6.12 – Critical Care Visits and Neonatal Intensive Care (Codes 99291 – 99292)

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Centers for Medicare and Medicaid (CMS)

QUESTIONS

Questions regarding policies, procedures or interpretations should be directed to the USC Office of Culture, Ethics and Compliance at (323) 442-8588 or USC Report & Response at (213) 740-2500 or (800) 348-7454.