Key Points for Billing and Coding Critical Care Services

Critical care medicine specialists diagnose and treat a wide variety of diseases. A multidisciplinary team approach is needed to care for critically ill patients. Though there are only two codes for critical care services, reporting critical care presents a challenge because of the rules and regulations involved. In fact, Medicare and commercial payers scrutinize the manner in which critical care services are billed. Documentation of medical necessity is crucial. Physicians can rely on expert coding and critical care medical billing services to bill critical care correctly based on the documentation.

Services must be medically necessary and meet the requirements of critical care services. Care provided to patients that do not meet all of the criteria for critical care is reported using the appropriate E/M code depending on the level of service provided.

  • Full Attention of Rendering Provider:

    • Services require the full attention of the provider rendering the service.
    • All-time reported should represent the time the provider actually was evaluating, managing, and providing patient critical care.
    • Time must be spent at the patient’s immediate bedside or elsewhere on the floor, or unit, so long as the provider is immediately available to the patient.
    • For any given period of time spent providing critical care services to a patient, the practitioner cannot provide services to any other patient during the same time period.
    • Only one physician or non-physician practitioner may bill for critical care services during any one single period of time even if more than one physician is providing care to a critically ill patient.
  • Critical care is a time-based service:

    • Time may be continuous or an aggregate of intermittent time spent by members of the same group and same specialty.
    • Progress notes must document the total time the critical care services were provided for each date and encounter entry. When multiple physicians are involved, the documentation must support the medical necessity of the critical care services rendered by each physician.
    • The time requirement of the initial critical care service must be met by only one physician or non-physician practitioner.
  • Multiple Physicians:

    • More than one physician can provide critical care at another time and be paid if the service meets critical care, is medically necessary, and is not duplicative care.
    • Concurrent care by more than one physician (generally representing different physician specialties) is payable.
    • Services may not be shared/split between a physician and a non-physician practitioner.
  • Coding critical care services:

    • CPT code 99291 is used to report the first 30 – 74 minutes of critical care on a given calendar date of service.
  • Same specialty:

    • Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician.
    • CPT code 99291 should be used once per calendar date per patient by the same physician or physician group of the same specialty.
  • Non-physician practitioners of the same group:

    • Physician time may not be combined with a non-physician practitioner of the same group practice.
    • Time is billed separately from the physician using the appropriate code.
    • May not bill the initial critical care code on the same day as the physician (e.g., if the physician provides 30 – 74 minutes of critical care services, the non-physician practitioner will bill CPT code 99292 for the additional time up to 30 minutes.)
  • Different specialty:

    • Physicians of a different specialty may each report CPT code 99291 if they are providing care that is unique to his/their individual medical specialty and managing at least one of the patient’s critical illness(es) or critical injury(ies)
  • Critical care of fewer than 30 minutes total duration on a given calendar date is not reported separately using the initial critical care CPT code (99291). This service should be reported using another appropriate E/M code [ensuring all components of the CPT descriptor are met] such as subsequent hospital care.
  • CPT code 99292 is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care:

    • Reporting CPT code 99291 is a prerequisite to reporting CPT code 99292.
    • Includes “staff coverage” or “follow-up” even if a different specialty.
    • Must bill one unit for every 30 minutes (e.g., an additional 60 minutes would be 2 units).

Avoiding Audits

When it comes to critical care services, the red flags that will attract the attention of insurance carrier auditors are inaccurate coding, insufficient or lack of documentation, nonadherence to payer policies, and lack of medical necessity. Unbundling procedures included in critical care or overuse of modifiers can also trigger an audit.

The following best practices can reduce the risk of payer audits:

  • Ensure accurate and up-to-date CPT and ICD-10 codes in claims. An experienced physician billing service provider can help with this.
  • Provide comprehensive documentation that supports the services that have been performed and billed.
  • Make sure documentation can support medical necessity for all billed services.
  • Be familiar with Medicare and private payer rules and policies on billing critical care services.
  • Avoid overutilization of critical care services, Unbundling services inappropriately with modifier 25 0r 59, billing for critical care when the patient does not meet the critical care definition, and other high-risk coding behavior.
  • Perform regular self-audits of procedures and E/M coding and documentation for errors and areas of risk.

Whether it’s using correct CPT codes or documenting medical necessity or documenting time, critical care billing and coding is a challenging task. Partnering with an experienced critical care medical billing service provider is a practical way to ensure accurate reporting and avoid audits. To know more about our critical billing and coding services, contact us at can contact us at 888-357-3226/