Corporate

October 4, 2013

Critical Care: Reminders

Codes

  • CPT Code 99291
    Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes
    • CPT Code 99292
      each additional 30 minutes (list separately in addition to code for primary service)

Definition

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.”

Time-based

Critical care is a time-based service, and for each date and encounter entry, the physician’s progress note(s) must document the total time that critical care services were provided.

  • If documentation supports medical necessity but the amount of time is not documented: the service will be denied as not medically necessary. It is a requirement that the time spent providing the care be documented.
  • If documentation supports critical care but is less than 30 minutes total in duration on a given calendar date, do not report the service as critical care. Use another appropriate Evaluation & Management (E/M) code.

Shared/Split with a Nonphysician Practitioner (NPP)

E/M services performed by both a physician and a qualified NPP of the same group practice (or employed by the same employer) cannot be reported as critical care service. Critical care services are reflective of the care and management of a critically ill or critically injured patient by an individual physician or qualified non-physician practitioner for the specified reportable period of time.

Critical Care Services Provided on Same day as Another E/M Service

When critical care services are provided on the same date date as an inpatient hospital or office/outpatient evaluation and management service (furnished earlier on the same date at which time the patient did not require critical care), both the critical care and the previous E/M service may be paid if documentation in the patient’s medical record supports the medical reasonableness and necessity of both services.

Palliative Care

CGS has maintained that the palliative care services CANNOT be submitted with critical care codes, as the palliative care does not meet the definition of critical care as stated above.

References: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12External PDF

  • Definition of critical care: section 30.6.12
  • Critical care and another E/M service provided on the same date: section 30.6.12.H
  • Counting time and units: sections 30.6.12.E, F, and G


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