Critical Care Services

What is Critical Care?

Medicare defines critical care as the direct delivery of medical care by a physician or qualified healthcare professional to a critically ill or critically injured patient whose condition involves acute impairment of one or more vital organ systems and a high probability of imminent or life-threatening deterioration. Critical care requires high-complexity medical decision making to assess, manipulate, and support vital organ system failure or prevent further deterioration. 

Critical care is based on:

• The patient's clinical condition 
• The provider's work and decision making 
• The medical necessity of the services furnished

The presence of a serious diagnosis alone does not establish medical necessity for critical care services. Documentation should demonstrate why the patient was critically ill and at risk of imminent deterioration at the time services were provided. Critical care is not determined solely by location. A patient in an ICU does not automatically qualify for critical care services, while a patient in another setting may qualify if critical care criteria are met.

Common Clinical Scenarios That May Support Critical Care

Examples may include:

• Acute respiratory failure
• Septic shock
• Cardiogenic shock
• Acute myocardial infarction with hemodynamic instability
• Multi-system trauma
• Severe metabolic derangements
• Acute neurologic deterioration
• Acute hepatic failure
• Life-threatening gastrointestinal bleeding

Documentation should describe the patient's critical condition, affected organ system(s), clinical instability, and risk of imminent deterioration rather than simply listing diagnoses. 

Common Clinical Scenarios That May Not Support Critical Care

Examples may include:

• The patient is stable despite being in an ICU
• The provider performs routine monitoring without imminent risk of deterioration
• Documentation does not demonstrate high-complexity medical decision making
• A serious diagnosis is present without evidence of critical illness
• Total critical care time is less than 30 minutes

Critical Care CPT Codes

CPT® code 99291 is critical care, evaluation and management of the critically ill or critically injured patient for the first 30–74 minutes.

CPT® code 99292 is critical care, evaluation and management of the critically ill or critically injured patient for each additional 30 minutes (list separately in addition to code for primary service).

Medicare requires a complete additional 30-minute increment before billing each unit of 99292.

What Time Counts Toward Critical Care?

Medicare allows critical care time for activities directly related to management of the critically ill or critically injured patient. The provider does not need to remain continuously at the bedside.

Countable Activities

• Bedside evaluation and reassessment
• Review of diagnostic studies
• Interpretation of physiologic data
• Ordering and adjusting treatments
• Coordination with consultants
• Medically necessary treatment discussions
• Direct documentation related to critical care services

Critical Care Time Documentation Tip

The medical record should reflect not only the total critical care time, but also the services performed during that time. Time statements without supporting documentation may not adequately support the reported service.

Family Discussions

Time spent with family members may be counted toward critical care when the discussion directly contributes to treatment decisions and the patient cannot participate. 

Documentation must support:

• Patient unable or incompetent to participate
• Discussion medically necessary
• Discussion directly impacted treatment decisions
• Time spent

Time is not countable:

• Routine status updates
• Social conversations
• Non-treatment-related discussions
• Discussions with family when the patient is competent to participate

Separately Billable Procedures

Time spent performing separately reportable procedures may not be included in critical care time calculations. Documentation should clearly separate procedure time from critical care time. 

Common examples:

• Endotracheal intubation
• Central venous catheter placement
• Arterial line insertion
• Chest tube placement
• Cardioversion

Documentation Tip 

When separately billable procedures are performed on the same date as critical care, providers should clearly document the total critical care time, procedure time, and that procedure time was excluded from critical care calculations.

Concurrent Critical Care

Multiple providers of different specialties may bill critical care on the same date when each provider manages different aspects of the patient's condition and documentation supports separate medically necessary contributions. 

Documentation should identify:

• Each provider's role and the specific conditions(s) managed
• Distinct medical management provided
• Separate time spent
• Separate medical necessity
• Duplicate billing for the same work is not permitted

Split (or Shared) Critical Care Services

CMS permits split or shared critical care visits when a physician and advanced practice practitioner in the same group jointly provide care. The practitioner performing the substantive portion of the service bills the encounter. The substantive portion is typically determined by more than 50% of the total critical care time. Modifier FS is required when applicable. 

Documentation should include:

• Time spent by the physician
• Time spent by the APP
• Specific activities performed by each practitioner
• Total combined critical care time

Medicare Time Thresholds

Total Critical Care Time	Codes
Less than 30 minutes	Appropriate E/M service, not critical care
30-74 minutes	99291
75-104 minutes	99291 + 99292 x1
105-134 minutes	99291 + 99292 x2

Critical Care Services and Neonatal Intensive Care CPT Codes 99291-99292	Things to Know (Visit CMS.gov for additional information)
Critical care-bundled services	Bundled services included by CPT in critical care services (and therefore not separately payable) include interpretations of cardiac output measurements, chest X-rays, pulse oximetry, blood gases and other physiologic data such as electrocardiograms (ECGs), blood pressures, hematologic data; gastric intubation, temporary transcutaneous pacing, ventilator management, and vascular access procedures.
Critical care by a single provider	CPT codes 99291 and 99292 will be used to report the total duration of time spent by the physician or non-physician practitioner (NPP) providing critical care services to a critically ill or critically injured patient, even if the time spent by the practitioner on that date is not continuous. Noncontinuous time for medically necessary critical care services may be aggregated.
Critical care visits furnished concurrently by different specialties	Concurrent care is when more than one physician renders services that are more extensive than consultative services during a period of time. The reasonable and necessary services of each physician furnishing concurrent care are covered when each plays an active role in the patient’s treatment. In the context of critical care services, a critically ill patient may have more than one medical condition requiring diverse, specialized medical services, and requiring more than one practitioner, each having a different specialty, playing an active role in the patient’s treatment. Medicare policy allows critical care visits furnished concurrently to the same patient on the same date by more than one practitioner in more than one specialty, regardless of group affiliation, if the service meets the definition of critical care, is medically necessary, and is not duplicative of other services.
Critical care furnished concurrently by practitioners in the same specialty and same group (follow-up care)	Physicians or NPPs in the same specialty and in the same group may provide concurrent follow-up care, such as a critical care visit subsequent to another practitioner’s critical care visit. This may be as part of continuous staff coverage or follow-up care to critical care services furnished earlier in the day on the same calendar date. CPT code 99291 may not be reported more than once for the same patient on the same date. If multiple practitioners are involved in the provision of 99291 services, the total time spent by those practitioners is aggregated toward the time requirement for this service. Code 99292 is reported when an additional 30 minutes of critical care services have been furnished to the same patient on the same date. Any aggregated time spent on critical care services must be medically necessary and must meet the definition of critical care. Medicare classifies NPPs in a specialty that is not the same as a physician. In these instances, guidance regarding split or shared critical care services must be followed.
Split or shared critical care visits	In the context of critical care, split or shared visits occur when the total critical care service time furnished by a physician and NPP in the same group on a given calendar date to a patient is summed, and the practitioner who furnishes the substantive portion of the cumulative critical care time reports the critical care service(s). The substantive portion for critical care services is defined as more than half of the total time spent by the physician or NPP beginning January 1, 2022. The billing practitioner (physician or NPP) bills the initial service (CPT 99291) and any add-on codes(s) for additional time (CPT 99292) based on substantive provision of those services. Critical care services can include additional activities bundled into the critical care visit code(s). There is a unique listing of these qualifying activities described in the prefatory language for critical care services in the CPT manual. To bill split or shared critical care services, the billing practitioner first reports CPT code 99291 and, if 104 or more cumulative total minutes are spent providing critical care, the billing practitioner reports one or more units of CPT code 99292. Modifier -FS (split or shared E/M visit) must be appended to the critical care CPT code(s) on the claim. When two or more practitioners spend time jointly meeting with or discussing the patient’s care, that time can be counted only once for purposes of reporting the split or shared critical care visit.
Critical care and other same day E/M visits	Physicians in the same group and in the same specialty must bill and be paid for services under the physician fee-schedule as though they were a single physician. If more than one E/M visit is provided on the same date to the same patient by the same physician, or by more than one physician in the same specialty in the same group, only one E/M service may be reported, unless the E/M services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. This general policy is intended to ensure that multiple E/M visits for a patient on a single day are medically necessary and not duplicative. In situations when a patient receives another E/M visit on the same calendar date as critical care services, both may be billed (regardless of practitioner specialty or group affiliation) as long as the medical record documentation notes that 1) the other E/M visit was provided before the critical care and at a time when the patient did not require critical care; 2) the services were medically necessary; and 3) the services were separate and distinct with no duplicative elements from the critical care services occurring later in the day. Additionally, the modifier -25 should be appended to the critical care services on the claim for this day.
Critical care visits and global surgery	When a critical care visit is unrelated to the procedure with a global surgical period, critical care visits may be paid separately in addition to the procedure. Preoperative and postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the full attention of the physician, and the critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed (for example, trauma or burn cases). When the critical care service is unrelated to the procedure, append the modifier -FT (unrelated E/M visit during a postoperative period, or on the same day as a procedure or another E/M visit).
Medical record documentation	Documentation needs to indicate the services furnished to the patient, including any concurrent care by the practitioners, are medically reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member. To support coverage and payment determinations regarding concurrent care, services must be sufficiently documented to allow a medical reviewer to determine the role each practitioner played in the patient’s care (that is, the condition or conditions for which the practitioner treated the patient). When critical care is furnished in conjunction with a global procedure, the documentation must support the critical care was unrelated to the procedure. Documentation is needed to support coverage and payment for split or shared critical care services as provided by the practitioner who performs the substantive portion of those services. Please refer to the "Split or shared critical care services" section above. Only distinct time can be counted. When the sharing practitioners are jointly providing services in conjunction with one another, only the time of one of the practitioners can be counted. One of the practitioners must have face-to-face contact with the patient. The substantive portion is determined by the proportion of total time, not whether the time involves patient contact. For split or shared critical care services, the documentation in the medical record must identify the provider who performed the visit. The individual who performed the substantive time portion of the service will be the one who bills for the service and that individual must sign and date the medical record. Best practice is for each practitioner to note the amount of time committed to the provided service.

Medical Record Documentation

A critical care note should support:

• Critical illness or injury
• High-complexity medical decision making
• Medical necessity
• Total critical care time
• Critical care activities performed
• Exclusion of separately billable procedure time

The documentation should allow a reviewer to clearly understand why the patient was critically ill or injured and how the conduction created a high probability of imminent or life-threatening deterioration, as well as the services personally performed by the billing practitioner.

Required Elements

Critical illness or injury

• Documentation must demonstrate an acute condition resulting in impairment of one or more vital organ systems and a high probability of imminent deterioration. Serious diagnoses alone do not establish critical care. 
• Document:
• Critical illness or injury
• Affected organ system(s)
• Severity of the condition
• Risk of deterioration
• Clinical instability

High-Complexity Medical Decision Making

• Documentation must demonstrate active management of a life-threatening condition. Auditors should be able to identify the provider's thought process, assessment, treatment decisions, and ongoing reassessment. 
• Document:
• Diagnostic evaluation
• Interpretation of clinical data
• Assessment of treatment response
• Escalation or modification of therapy
• Risk-benefit decisions
• Specialist collaboration
• Management of organ failure

Medical Necessity

• The record must clearly explain why critical care was medically necessary and what life-threatening risk was being managed. A serious diagnosis alone does not establish critical care medical necessity. 
• Document:
• Why the patient was critically ill
• The specific risk of deterioration
• The intervention required
• How provider management affected outcomes

Total Critical Care Time

• Critical care is a time-based service. The medical record should include the total amount of time spent personally providing critical care services on the date of service. 
• Documentation should include:
• Total minutes
• Date of service
• Activities performed
• Exclusion of procedure time

Critical Care Documentation Risks

During medical review critical care services may be denied when documentation does not clearly support the medical necessity, complexity, and time requirements of the service. Common findings include:

• No documentation demonstrating an imminent or life-threatening deterioration in the patient's condition 
• Critical care time not documented or not clearly supported by the medical record 
• Separately billable procedure time included in the reported critical care time 
• Diagnoses reported without documentation of the associated clinical severity, instability, or organ system dysfunction 
• Insufficient evidence of high-complexity medical decision making 
• Failure to clearly document active management of a critically ill or injured patient 
• Documentation that reflects routine monitoring or standard patient care rather than critical care services 
• Cloned, copied, or templated documentation that does not accurately reflect the patient's current condition and treatment

Example: Documentation should demonstrate the patient's evolving clinical status and the provider's ongoing assessment and management. Identical assessments, treatment plans, organ failure descriptions, or critical care time statements repeated across multiple dates of service may not support the dynamic nature of critical illness and may raise concerns regarding the accuracy and medical necessity of the reported critical care services.

Documentation Best Practices

Providers should ensure that each critical care note includes:

• The patient's current clinical status
• Updated physical examination findings
• Changes in organ system function
• Current diagnostic data and interpretation
• New or revised treatment decisions
• The patient's response to interventions
• Actual critical care time provided on that date of service
• Patient-specific medical decision making

Compliance Tip

The use of templates and copied-forward documentation may be used to improve consistency, but critical care notes should clearly demonstrate the unique circumstances, clinical findings, and management decisions for each encounter. Documentation should accurately reflect the patient's condition, services performed, medical decision making, and critical care time for the date of service and support the medical necessity of the critical care services reported.

If yesterday's critical care note could be submitted for today's encounter without significant modification, the documentation may not adequately support Medicare billing requirements. Each critical care encounter should reflect the patient's changing condition, the provider's current assessment, and the services personally performed on that date.

Critical Care Checklist

Before billing critical care services, confirm the medical record supports:

• Critical illness or critical injury
• Acute impairment of one or more vital organ systems
• High probability of imminent deterioration
• High-complexity medical decision making
• Medical necessity
• Critical care activities performed
• Total critical care minutes
• Exclusion of separately billable procedure time
• Appropriate documentation for family discussions
• Complete split/shared documentation, when applicable
• Distinct documentation for concurrent critical care services

 

References

• The Medicare Claims Processing Manual, Chapter 12, 30.6.12 - Critical Care Visits and Neonatal Intensive Care (Codes 99291 and 99292) 
• MLN006764 - Evaluation and Management Services (Critical Care Services Section) 
• CMS FAQs: Split (or Shared) Visits and Critical Care Services