Critical care cpt codes and additionas CPT should not billable

Critical care cpt codes and additionas CPT should not billable

PROCEDURE CODES NOT BILLABLE IN ADDITION TO CRITICAL CARE (99291 &

99292): Medicaid

FROM TO                FROM TO           FROM TO               FROM    TO

31500 31500              43752 43752          92265 92275          95925 95937

36000 36440              51100 51100           92280 92287          99090 99091

36468 36479 5           1701 51702            92950 93299           99170 99199

36510 36510              62270 62270          93303 93352          99460 99463

36555 36555              71010 71020          93561 93562

  

36591 36591              82800 82820           93668 93799

36600 36680             91105 91105           93875 94799

• Procedure codes 99291, 99292, 99466 and 99467 may be billed by the physician providing the care of the critically ill or injured patient in place of service 41, Ambulance, if care is personally rendered by the physician providing the care of the critically ill or injured patient.

When to use CRITICAL CARE SERVICES (CODES 99291-99292)

Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292)

CRITICAL CARE SERVICES (CODES 99291-99292)

 Use of Critical Care Codes

Pay for services reported with CPT codes 99291 and 99292 when all the criteria for critical care and critical care services are met. Critical care is defined as the direct delivery by a physician(s) 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 functions(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, 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. 

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 above requirements.

Critical care is usually, but not always, given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit, or the emergency department. However, payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care. Consult the American Medical Association (AMA) CPT Manual for the applicable codes and guidance for critical care services provided to neonates, infants and children.

Critical Care - Full Attention of Physician and teaching physician

Critical Care Documentation – Full Attention of Physician 

Since critical care is a time-based service, the physician ’ s critical care note(s) must document the total time spent evaluating, managing and providing critical care services to a critically ill or injured patient. Critical care time may be continuous or intermittent in aggregated time increments. Time spent performing separately billable procedures/services cannot be used to support critical care time. 

The time spent providing critical care services must be spent at the immediate bedside or elsewhere on the floor or unit as long as the physician is immediately available to the patient. Therefore, the physician cannot provide services to any other patient during the same period of time. 

Teaching Physician 

In the teaching environment, the teaching physician must be present for the entire period of time for which the claim is submitted. Time spent teaching may not be counted towards critical care time. The teaching physician, in addition, cannot bill for time spent by the resident providing critical care services in their absence. Only time that the teaching physician spends with the patient, or that he/she and the resident spend together with the patient, can be counted toward critical care time.

Provided that all requirements for critical care services are met, the teaching physician ’ s documentation may tie into the resident's documentation. The teaching physician may refer to the resident ’ s documentation for specific patient history, physical findings and medical assessment. 

NOTE: It is the teaching physician ’ s “ stand alone ” documentation that determines whether a critical care services can be billed. 

The teaching physician medical record documentation must provide information including the time the teaching physician spent providing critical care; that the patient was critically ill during the time the teaching physician saw the patient; what made the patient critically ill; and the nature of the treatment and management provided by the teaching physician. 

The following is an example of acceptable teaching physician documentation: 

Patient seen and examined with Dr. Resident. Reviewed and agree with his note and the plan of care we developed together. One hour of critical care time personally performed due to patient ’ s hemo-dynamic instability. Patient was resuscitated with 2 units of packed red blood cells. Additional studies were obtained to determine possible causes for patient ’ s instabilities.

Critical Care Services

Hospitals should separately report all HCPCS codes in accordance with correct coding principles, Procedure  code descriptions, and any additional CMS guidance, when available. Specifically with respect to Procedure  code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), hospitals must follow the Procedure  instructions related to reporting that Procedure  code. 

Prior to January 1, 2011, any services that Procedure  indicates are included in the reporting of Procedure  code 99291 (including those services that would otherwise be reported by and paid to hospitals using any of the Procedure  codes specified by Procedure ) should not be billed separately by the hospital. 

Instead, hospitals should report charges for any services provided as part of the critical care services. In establishing payment rates for critical care services, and other services, CMS packages the costs of certain items and services separately reported by HCPCS codes into payment for critical care services and other services, according to the standard OPPS methodology for packaging costs.

Beginning January 1, 2011, in accordance with revised Procedure  guidance, hospitals that report in accordance with the Procedure  guidelines will begin reporting all of the ancillary services and their associated charges separately when they are provided in conjunction with critical care. CMS will continue to recognize the existing Procedure  codes for critical care services and will establish payment rates based on historical data, into which the cost of the ancillary services is intrinsically packaged. 

The I/OCE conditionally packages payment for the ancillary services that are reported on the same date of service as critical care services in order to avoid overpayment. The payment status of the ancillary services does not change when they are not provided in conjunction with critical care services. Hospitals may use HCPCS modifier -59 to indicate when an ancillary procedure or service is distinct or independent from critical care when performed on the same day but in a different encounter.


Beginning January 1, 2007, critical care services will be paid at two levels, depending on the presence or absence of trauma activation. Providers will receive one payment rate for critical care without trauma activation and will receive additional payment when critical care is associated with trauma activation.

To determine whether trauma activation occurs, follow the National Uniform Billing Committee (NUBC) guidelines in the Claims Processing Manual, Pub 100-04, Chapter 25, §75.4 related to the reporting of the trauma revenue codes in the 68x series. 

The revenue code series 68x can be used only by trauma centers/hospitals as licensed or designated by the state or local government authority authorized to do so, or as verified by the American College of Surgeons. Different subcategory revenue codes are reported by designated Level 1-4 hospital trauma centers. 

Only patients for whom there has been prehospital notification based on triage information from prehospital caregivers, who meet either local, state or American College of Surgeons field triage criteria, or are delivered by inter-hospital transfers, and are given the appropriate team response can be billed a trauma activation charge.

When critical care services are provided without trauma activation, the hospital may bill Procedure  code 99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (and 99292, if appropriate). 

If trauma activation occurs under the circumstances described by the NUBC guidelines that would permit reporting a charge under 68x, the hospital may also bill one unit of code G0390, which describes trauma activation associated with hospital critical care services. Revenue code 68x must be reported on the same date of service. 

The OCE will edit to ensure that G0390 appears with revenue code 68x on the same date of service and that only one unit of G0390 is billed. CMS believes that trauma activation is a one-time occurrence in association with critical care services, and therefore, CMS will only pay for one unit of G0390 per day.

The Procedure  code 99291 is defined by Procedure  as the first 30-74 minutes of critical care. This 30 minute minimum has always applied under the OPPS. The Procedure  code 99292, Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes, remains a packaged service under the OPPS, so that hospitals do not have the ongoing administrative burden of reporting precisely the time for each critical service provided. As the Procedure  guidelines indicate, hospitals that provide less than 30 minutes of critical care should bill for a visit, typically an emergency department visit, at a level consistent with their own internal guidelines.

Under the OPPS, the time that can be reported as critical care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or critically injured patient. If the physician and hospital staff or multiple hospital staff members are simultaneously engaged in this active face-to-face care, the time involved can only be counted once.

• Beginning in CY 2007 hospitals may continue to report a charge with RC 68x without any HCPCS code when trauma team activation occurs. In order to receive additional payment when critical care services are associated with trauma activation, the hospital must report G0390 on the same date of service as RC 68x, in addition to Procedure  code 99291 (or 99292, if appropriate.)

• Beginning in CY 2007 hospitals should continue to report 99291 (and 99292 as appropriate) for critical care services furnished without trauma team activation. Procedure  99291 maps to APC 0617 (Critical Care). (Procedure  99292 is packaged and not paid separately, but should be reported if provided.)