June 1, 2021

Is It Really Critical Care?


Are the claims your office is submitting for critical care really subsequent hospital visits? According to the 2020 Medicare FFS Supplemental Improper Payment Date Report (Report), the critical care hospital visit improper payment rate is approximately 20%!  Critical care is also ranking in the top 5 types of services with upcoding errors for Part B claims.

So, your Medicare Administrative Contractor (MAC) and other payers using Medicare payment errors are all potentially monitoring your critical care coding to detect a reason to conduct an audit.  I highly recommend coders and medical billing companies working for Intensivists, Hospitalists and Specialists that are billing 99291/99292 to perform periodic audits to ensure documentation supports information reported on your claims.

According to the Report, the first hour of critical care, code 99291, has an overpayment rate of 19.7%, based on 269 claims and 310 line-items reviewed.  What is the accuracy or error rate for your providers?  Do you know?  Is it time to find out?  First, know the rules.

Don’t Make These Common Mistakes

During either investigative or internal audits that I have personally conducted, I have found two main contributing factors related to incorrect coding of critical care.

1.  Critical care and other E/M services may be provided to the same patient on the same date by the same provider.  This means you can’t bill shared/split visits (which is permitted for other Evaluation & Management encounters in the hospital).

  • Critical care billing means one provider and the time that provider has spent rendering critical care services to that individual.

2.  Just because a patient is in the Intensive Care Unit (ICU) or other critical bed status, you can’t automatically bill 99291 and/or 99292.  As stated in the guidelines, “Services for a patient who is not critically ill but happens to be in a critical care unit are reported using other appropriate E/M codes.”

  • Report subsequent hospital visit codes 99221-99223 when the patient is in a critical care bed but does not require critical care intervention.

First, let’s review the AMA’s CPT® codes for critical care coding accuracy.

Coding Correctly

Understand the definition, documentation and reporting guidelines related to critical care codes 99291 and 99292.

99291        Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes

  • Code 99291 is used to report the first 30-74 minutes of critical care on a given date. It should be used only once per date even if the time spent by the individual is not continuous on that date. Critical care of less than 30 minutes total duration on a given date should be reported with the appropriate E/M code.

+99292      Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service)

  • Code 99292 is an add-on code and always used in conjunction with code 99291 and used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes.

Correctly Calculate Time for Coding and Reporting Purposes

Time spent with the individual patient should be recorded in the patient’s record.

The time that can be reported as critical care is the 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.

  • For example, time spent on the unit or at the nursing station on the floor reviewing test results or imaging studies, discussing the critically ill patient’s care with other medical staff, or documenting critical care services in the medical record would be reported as critical care, even though it does not occur at the bedside.
  • When the patient is unable or lacks capacity to participate in discussions, time spent on the floor or unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care, provided that the conversation bears directly on the management of the patient.

This table illustrates the correct reporting of critical care services:

Time You Can’t Count

Time spent in activities that occur outside of the unit or off the floor (e.g., telephone calls whether taken at home, in the office, or elsewhere in the hospital) may not be reported as critical care since the individual is not immediately available to the patient.

Time spent in activities that do not directly contribute to the treatment of the patient may not be reported as critical care, even if they are performed in the critical care unit (e.g., participation in administrative meetings or telephone calls to discuss other patients). Time spent performing separately reportable procedures or services should not be included in the time reported as critical care time.

You can’t count time split between other patients on the floor. Time doesn’t have to be continuous, however, the treating provider must devote his/her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.

Documentation Must Meet the Definition of Critical Care

Critical care is the direct delivery by a physician(s) or other qualified healthcare professional (QHP) of medical care for a critically ill or critically injured patient. Providing medical care to a critically ill, injured, or post-operative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the requirements stated below.  These requirements should be recorded in the patient’s medical record and available upon audit.

Critical care is usually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or the emergency care facility.

Documentation must reflect that the provider has intervened in a critical illness or injury for that patient that day.  This means that the illness or injury has acutely impaired one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition.

Medical decision-making must be highly complex. Critical care involves high complexity decision-making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition. Examples of vital organ system failure include, but are not limited to:

  • Central nervous system failure;
  • Circulatory failure;
  • Shock; and
  • Renal, hepatic, metabolic, and/or respiratory failure.

Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present. Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patient’s condition continues to require the level of attention described above.

Bundle Appropriately

For reporting purposes, CPT bundles various services into critical care.  These services are routinely conducted by providers during the time of the highly complex critical care. According to CPT®, the following services are included in critical care when performed during the critical period by the provider rendering critical care:

  • Interpretation of cardiac output measurements;
  • Chest X-rays;
  • Pulse oximetry;
  • Blood gases, and collection and interpretation of physiologic data (e.g., ECGs, blood pressures, hematologic data);
  • Gastric intubation;
  • Temporary transcutaneous pacing;
  • Ventilatory management; and
  • Vascular access procedures.
  • Any services performed that are not included in this listing should be reported separately.



2020 Medicare FFS Supplemental Improper Payment Data Report

Become a Healthcare Compliance Auditor

Consider training in outpatient medical documentation improvement

Download the 2021 CMS Evaluation and Management Services Guide


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