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Risks Associated with Critical Care Coding

Questions abound when reporting critical care services.

Reporting Adult Critical care can be complicated. It is not only the coding but the rules and that go along with critical care.  Many questions come up when reporting critical care services. You would think it would be fairly straightforward since there are only two codes for adult critical care, 99291 for the first 30-74 minutes and 99292 for each additional 30 minutes in a calendar date.  But questions always arise when a practitioner is performing critical care.

Supporting Medical Necessity for Critical Care

According to CPT® 2017: “Critical care is the direct delivery by a physician(s) or other qualified health care professional 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 function(s) to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition.”

According to CMS and other payers, critical care must be medically necessary and is a service as service that encompass both treatment of “vital organ failure” and “prevention of further life-threatening deterioration of the patient’s condition”.

Examples that would meet the criteria for critical care include the following:

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

If a patient has a potential of further deterioration is that critical care?  What about the patient who is on a vent but is stable?  Does this qualify for critical care? A patient who you are providing chronic ventilator management may not be considered critical unless they meet the critical care definition even if they are being managed in the critical care unit.  A patient who had surgery and is placed in critical care for constant observation might not meet the definition if there is not a potential of life threatening deterioration.  So understanding what constitutes critical care is vital in reporting the services accurately.  A patient on dialysis or hemodialysis would not be considered critical unless the patient’s condition is more than long term management of dialysis dependence.

It’s all about the Documentation

Although there are no key component requirements for critical care, when the patient is admitted to critical care or meets the definition of critical care such an acute MI arriving in the ER, a complete history and physical examination should be documented along with any lab results, bedside procedures even if included in the critical care time, a detailed assessment and comprehensive plan of care.  For all subsequent visits whether on the same date or different date the documentation should reflect the critical status of the patient, an examination, any change in treatment plan, labs and/or bedside procedures.  As always total time spent should be documented for each critical care encounter and the codes billed (99291 and 99292) should reflect the total time spent on the date of service.

What I find many times when reviewing documentation is the physician who put patients in critical care even if not critical are still billing for critical care services which during a payer audit can result in recovery of dollars from the practitioner.  Just because the patient is in critical care or was critical two days ago does not mean today he/she is critical.

The key is the status of the patient.  Once the patient is no longer critical coding should change to the subsequent hospital care codes 99231-99233 based on documentation and the complexity of the patient no matter where the patient is located in the hospital. For example, if the cardiologist billed critical care yesterday for example and then discharges the patient using CPT codes 99238-99239 it sends a “red flag” to the payers.  The question arises, why would a physician discharge a critically ill patient?

Critical Care documentation should always include the following:

  • The organ system(s) at risk
  • Which diagnostic and/or therapeutic interventions were performed, including rationale
  • Critical findings of laboratory tests, imaging, ECG, etc., and their significance
  • Course of treatment (plan of care)
  • Likelihood of life-threatening deterioration without intervention

A patient who is critically ill typically has a laundry list of comorbid conditions. When coding for critical care services, it is appropriate for the physician to code and report the patient’s underlying or comorbid conditions even if the physician is managing only one condition, such as respiratory distress, acute myocardial infarction, stroke, injury or any condition that requires critical care.

The International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) can accommodate more specificity when describing acute, subacute and chronic conditions. Documentation of the reason for providing the critical care services should include the principle/first listed diagnosis followed by any comorbidities that affect the patient’s care. Often the physician reports only the condition he/she is managing, but this does not always provide a true picture of the patient’s condition

How do you Document Time?

Adult Critical care is time based.  It is reported for all patients who are critically over the age of 5 years old.  If the patient is under 5, the neonatal or pediatric critical care codes are reported. As stated earlier 99291 if reported for the first 30-74 minutes of critical care time and 99292 is reported for each additional 30 minutes. Per CPT Guidelines, if the critical care patient is managed less than 30 minutes in a calendar day, a subsequent hospital visit codes 99232-99233 based on the key components documented is reported.   Once the patient is no longer critical status the subsequent care codes should be reported. Time can be documented as total time or start and stop times.  Many consultants recommend start and stop times, but CPT and CMS do not mandate start and stop times. However, you should carve out the time spent performing procedures or services not bundled into critical care and make certain the documentation reflects that the time was not counted.

Example: Critical care time: 134 minutes 99291-25 and 99292-25 x 3
93503 (Insertion and placement of flow directed catheter (e.g., Swan-Ganz)
for monitoring purposes (16 minutes)
Total time spent:  2 hours, 30 minutes

This clearly differentiates the critical care time from the Swan-Ganz Catheter which is not bundled into critical care and can be reported separately.  It is helpful to document the time spent in performing a procedure not bundled into critical care as well as critical care time. Don’t forget to append Modifier 25 to the E/M services to identify that the E/M service is significantly identifiable from the procedure.  The procedure note should also be well documented.

Keep in mind however, if the procedure is included in the critical care services such as gastric intubation (42752 or 42752) count the time while performing the procedures in your critical care time but do not report the procedure separately as it is bundled into critical care.  However, the procedure should be well documented. You can find the services that are bundled into critical care in the American Medical Association Current Procedural Terminology (Professional 2017).

Services included in the calculation of critical care time should include following:

  • Providing medical care at the patient’s bedside.
  • Discussing the patient’s medical condition with other practitioners or other members of the care team when on the unit and immediately available to the patient.
  • Reviewing diagnostic tests and data related to the patient.
  • Performing procedures that are bundled into the payment of critical care including procedures performed at the bedside.
  • Discussions with the family if the discussion with the family involves obtaining history that the patient is unable to give or discussion with the family required because a family member must make medical decisions for the patient.
  • Writing or dictating notes in the chart or electronic health record.

In order to report critical care, the practitioner must be immediately available to the patient.  That means the practitioner cannot be at home talking to another physician in the ICU about the patient, cannot see other patients on the floor or in other units of the hospital.  Critical care does not need to be continuous.  It can be intermittent and provided at various times during the calendar date of service.  To finish the billing for your critical care patient for the particular date of service, total all time for that date and report based on total time.

Only one practitioner may bill for critical care during a specific time period even if more than one physician is managing the patient who is critical.  For example, if a cardiologist is managing a critical care patient from 10:00 pm-11:00 pm, and a pulmonologist is managing the patient at the same time, only one physician can bill for that time frame.  But if the cardiologist is managing the critical portion from 1:00-1:45 and the pulmonologist manages their portion of the service from 2:30-3:15 both practitioners can bill for critical care services as long as they are managing different conditions.  The diagnosis play a significant role in differentiating that they are managing separate problems.

When to Use Critical Care Codes:

  • Patients who are critically ill or unstable with a high probability of imminent life-threatening deterioration.
    • i.e., treatment of “vital organ failure” and “prevention of further life-threatening deterioration” (Medicare)
  • For critical care services 30 minutes or greater.
  • Physician provides his or her full attention; cannot provide services to other patient at the same time.
  • Total time spent in the treatment of the patient should be documented in the patient’s record; Constant bedside attendance is not required.


When NOT to Use:

  • Patients in the ICU who do not meet the definition of critical care.
  • Patients who are in the post-operative global period and the critical care is related to the surgery.
  • When critical care services do not equal or exceed 30 minutes. Use the appropriate E/M code.
  • Rounding in the critical care unit when the patient is not critical. This is reported as subsequent hospital care (9923x) if not related to an operative procedure (non-global care).


Services that may not be included in critical care time include the following:

  • Updating family members who are not making medical decisions
  • Teaching time with interns, residents and other providers
  • Researching the patient’s condition
  • Time spent off the unit not providing care directly related to the patient
  • Time spent caring for other patients either in the unit or in another area of the hospital
  • Time spent performing procedures for which a separate charge is made (services not included in critical care time
  • Time spent in typical follow up for all patients
  • For Medicare patients, time spent in caring for complications that are related to a procedure



Understanding what meets medical necessity for a critical care service is imperative when reporting critical care.  Critical care service contain higher are scrutinized by payers because the RVU’s are significantly higher.  Make certain documentation for chart entry includes the status of the patient and enough detail in the documentation to support medical necessity for billing critical care and once the patient’s status changes from critical to stable no matter where the patient is located in the hospital, report the subsequent visit codes.

Total time should be documented every time the patient is managed by the practitioner and the total time should be the factor when selecting 99291-99292.  Keep up to date on changes to critical care guidelines for CMS and other payers.  A good source of reference is the CMS Internet Only Manual; Publication 100-4; Chapter 12: Section 30.6.12 and the CPT Guidelines.

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