26 Feb 2018

CPT 99291 - 99292

Critical Care Service:


          Is a branch of medicine, Focused on management of life-threatening conditions / critically ill patient. Critical care is the direct delivery by a physician or other health care professional for a critically ill patient.


         Critical care involves high complexity decision making to treat single or multiple vital organ system failure and to prevent further life-threatening deterioration of the patient’s condition.


Examples of vital organ system failure,


     1. Circulatory failure

     2. Nervous system failure

     3. Renal failure

     4. Hepatic failure

     5. Respiratory failure


Critical care may be provided on multiple days if no changes occur in the patient’s health condition.   


Critical care is usually given in Critical care unit, or coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit or emergency department.


Critical care time spent with the individual patient should be documented in the patient’s medical record.


Critical care time:   


       1. Physician’s total time spent engaged in work directly related to the patient’s care (Immediate bedside or elsewhere on the floor or unit reviewing test results or imaging studies, discussing the case with other medical staff) are considered as critical care time.


       2. If the physician spent time with the patient’s family members or surrogate decision-makers obtaining a medical history or prognosis or treatment limitations are also considered as Critical care time.


Note: Time spent in activities that do not directly contribute to the treatment of the patient should not be reported as critical care time even though if they are performed in the critical care unit (Eg: participation in other meetings, or telephone calls to discuss other patients).


    Time spent on performing other procedures or services that can be coded separately should not be included in critical care time.


Included services:


   1. Interpretation of cardiac output measurements (93561, 93562)

   2. Chest x rays (71045, 71046)

   3. Pulse oximetry (94760, 94761, 94762)

   4. Blood gases and information data stored in computers [Eg, ECGs blood pressure, hematologic data (99090)]

   5. Gastric intubation (43752, 43753)

   6. Temporary transcutaneous pacing (92953)

   7. Ventilatory management (94002-94004, 94660,94662)

   8. Vascular access procedures (36000, 36410, 36415, 36591, 36600)


Note: Facilities may report the above service separately.


Excluded services:


       1. Any services performed that are not included in the above listing should be reported separately along with critical care services CPT codes.


Critical care CPT codes are time-based codes.


       1. CPT 99291 – First 30 – 74 minutes of critical care service to the critically ill patient


       2. CPT 99292 – each additional 30 min.  


Age-based Critical Care codes related to the place of service:




    1. Infant 28 days of age or younger, Report CPT 99468, 99469


  2. Infant 29 days – 71 months of age, Report CPT 99471 – 99476


Outpatient (Emergency or Office)


    1. For neonates and pediatric patient up through 71 months of age, report CPT 99291, 99292


Note: If the same physician provides critical care service for a neonate / pediatric patient in both outpatient and inpatient settings on the same day, report only the appropriate neonatal/pediatric critical care code 99468-99472.


Transporting critically ill patient from the facility to facility or hospital to hospital


    1. Older than 24 months of age, report CPT 99291, 99292


    2. Younger than 24 months of age, report CPT 99466, 99467



Billing Guidelines:


    Services provided to a patient who is in critical care unit but not critically ill, shouldn’t be coded as critical care services, instead of code appropriate E&M. 


    Critical care of less than 30 min on a given date shouldn’t be coded as critical care services, instead of code appropriate E&M


    Critical care services of total time (Not continuous / continuously) 30 to 74 minutes on a given date should be reported with CPT 99291.


    For an additional 30 minutes of time beyond the first 74 min should be reported with add on code 99292 along with primary procedure CPT 99291.


    Eg: For total CC Time with appropriate critical care codes are given below,


        1) Less than 30 min of critical care service – Code only appropriate E&M codes


        2) 30 – 74 min of CC service – CPT 99291


        3) 75 – 104 min of CC service – CPT 99291, 99292


        4) 105 – 134 min of CC service – 99291, 99292 x 2


        5) 135 – 164 min of CC service – 99291, 99292 x 3


        6) 165 – 194 min of CC service – 99291, 99292 x 4


Critical care and other E&M services may be provided by the same physician to the same patient on the same day.


No individual should report the remote real-time interactive video conference critical care services CPT 0188T, 0189T for the period in which other physician reports CPT 99291, 99292.