UC San Diego Health Sciences
Compliance Program
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Professional Fee Billing Guidance
Frequently Asked Questions: Critical Care Services
99291
Critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 minutes
99292
Critical care, each additional 30 minutes (List separately in addition to code for primary services)
1. What is the CPT definition of critical care service (99291 and 99292)? CPT defines a critical illness or injury as an
illness or injury that 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 services are defined as a
physician's direct delivery of medical care for a critically ill or critically injured patient. It involves decision making of
high complexity to assess, manipulate, and support 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. Centers for Medicaid and Medicare Services (CMS) adds that in order to qualify as critical care for Medicare
patients, "the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically
significant or life threatening deterioration in the patient's condition".
2. How does Medicare's definition of critical care services differ from the AMA CPT manual? In July 2008, CMS
released Transmittal 1548 which represents the most recent update for the Medicare payment policy for critical
care services. The Transmittal includes the AMA CPT definitions of critical care and critical care services. CMS adds
that critical care services must be medically necessary and reasonable and specifically that the critically ill or injured
patient must meet the definition and criteria described above. [Refer to references for web-link]
3. How is teaching physician time measured for the purpose of determining the correct critical care code(s)? The
duration of critical care services for both CPT and Medicare is based on the attending physician’s documentation of
total time spent evaluating, managing, and providing care to the critical patient, as well as time spent in
documenting such activities. During this time the physician must devote full attention to the particular patient. This
time may be spent at the patient’s immediate bedside or elsewhere on the unit, so long as the physician is
immediately available to the patient. Physician time for critical care services encompasses time spent engaged in
work directly related to the individual patient’s care whether that time was spent at the immediate bedside or
elsewhere. For example, time spent can be at the bedside, reviewing test results, discussing the case with staff,
documenting the medical record and time spent with family members (or surrogate decision makers) discussing
specific treatment issues when the patient is unable or clinically incompetent to participate in providing history or
making management decisions. The "critical care clock" stops when separately reportable procedures or services are
performed; these should not be included in the total time reported as critical care time. Time involved in activities
that do not directly contribute to the treatment of the critical patient may not be counted toward the critical care
time. Critical care time does not need to be continuous. Non-continuous time for critical care services may be
aggregated in reporting total critical care time. CPT code 99291 is used to report the first 30-74 minutes of critical
care. CPT code 99292 is used to report additional block(s) of time of up to 30 minutes each beyond the first 74
minutes of critical care. (Example: For critical care time of 35 minutes, report 99291 x 1 only. For critical care time of
115 minutes report 99291 x 1, and 99292 x 2) Critical care time of less than 30 minutes is not reported using the
critical care codes. Such service should be reported using the appropriate E/M code. Only the time based critical
care codes (99291 and 99292) may be reported for services in the ED. The daily neonatal (99468-99469) and
pediatric (99471, 99472, 99475 and 99476) codes are only used in the inpatient setting.
Prepared by: Suzanne Forrest, 619-471-9154, sforrest@ucsd.edu
Date issued: 02/12/2012
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4. What are the key documentation requirements for use of the critical care service codes 99291 and 99292?
Providing medical care to the critical patient qualifies as a critical care service only if both the illness or injury and
the treatment being provided meet the above requirements. The attending physician’s medical record
documentation must provide substantive information:
a. The patient’s condition must meet the definition of a critical illness or injury described above.
b. The total critical care time delivered must be documented and must be a minimum of 30 minutes, exclusive
of separately reportable procedure time(s).
c. Clinical reassessments and documentation must support the amount of critical care time aggregated and
should include a description of all of the physician's interval assessments of the patient's condition, any
"impairments of organ systems" based on all relevant data available to the physician (i.e., symptoms, signs
and diagnostic data), the rationale and timing of interventions and the patient's response to treatment.
d. It is recommended that the physician note that "time involved in the performance of separately reportable
procedures was not counted toward critical care time". Failure to do so might result in the critical care time
being reduced by payers to account for any concurrent separately billable services.
5. What are the key performance and documentation requirements for use of the critical care service codes with
regard to Medicare’s Teaching Physician criteria? Time spent alone by the resident (i.e., performing critical care
activities in the absence of the teaching physician) cannot be counted toward critical care time. Only time spent
performing critical care activities by the resident and the teaching physician together or the teaching physician alone
can be counted toward critical care time. The teaching physician may tie into the resident’s documentation and may
refer to the resident’s documentation for specific patient history, physical findings and medical assessment.
However, the teaching physician must still document a statement of the total time the teaching physician personally
spent providing critical care, that the patient was critically ill when 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.
a. Example of unacceptable teaching physician documentation: “I came and saw (the patient) and agree with
(the resident)”.
b. Example of acceptable teaching physician documentation: "Patient developed hypotension and hypoxia. I
spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I
reviewed the resident's documentation and I agree with the resident's assessment and plan of care."
6. Can a critical care service code be reported with an E/M code for a patient cared for by the same physician on the
same calendar day? Yes! CPT allows for reporting both an E/M service and a critical care service on the same day.
Additionally, CPT does not distinguish as to site of service or which service comes first. Some payers may require the
modifier -25 to be attached to the non-critical care EM service (see below).
7. Can a critical care service code be reported with an E/M code for a Medicare patient cared for by the same
physician on the same calendar day? CMS Transmittal 1548 specifically addresses this question with regard to the
emergency department. It states that when critical care services are required upon arrival into the emergency
department, only critical care codes (99291 - 99292) may be reported. An emergency department E/M code (9928199285) may not also be reported (by the same physician). Although CMS understands that a patient may need
critical care services on the same day where the patient may have only required an inpatient or office/outpatient
E/M service earlier in the day, Transmittal 1548 clearly states that hospital emergency department services are not
payable for the same calendar date as critical care services when provided by the same physician (which includes
any physician of the same specialty in the same group) to the same patient. In other words, if a Medicare patient
presents to the emergency department and receives a Level 5 ED E/M workup, and later in the shift unexpectedly
Prepared by: Suzanne Forrest, 619-471-9154, sforrest@ucsd.edu
Date issued: 02/12/2012
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clinically deteriorates requiring critical care services, according to CMS the "same" ED physician can only report
either the ED E/M service or the critical care service -- but not both.
8. According to CPT which procedure codes are considered to be bundled into the critical care code? The following
services are included in "critical care” clock time when performed during the critical period by the same physician(s)
providing critical care and should not be reported separately. Any services performed that are not listed below may
be reported separately. :
a. Interpretation of cardiac output measurements (CPT 93561, 93562)
b. Pulse oximetry (CPT 94760, 94761, 94762)
c. Chest x-rays, professional component (CPT 71010, 71015, 71020)
d. Blood gases and information data stored in computers (e.g., ECGs, blood pressures, hematologic data, CPT
99090)
e. Gastric intubation (CPT 43752, 91105)
f. Transcutaneous pacing (CPT 92953)
g. Ventilator management (CPT 94002-94004, 94660, 94662)
h. Vascular access procedures (CPT 36000, 36410, 36415, 36591, 36600)
9. Does Medicare differ from CPT in the way it addresses bundling of critical care services and procedures? Medicare
bundles the same services included in critical care by CPT (see FAQs #7 & #8 above) when performed by the same
physician(s) reporting critical care. However, Medicare differs in that the relevant time frame for bundling pertains
to the entire calendar day for which critical care is reported, rather than limiting the time frame to just the period of
time that the patient is critically ill or injured during that calendar day.
10. What are some examples of procedures that could be billed separately from critical care? The "critical care clock"
stops when performing non-bundled, separately billable procedures. Examples of common procedures that may be
performed for a critically ill or injured patient include (but not limited to):
a. CPR (92950) (while being performed)
b. Endotracheal intubation (31500)
c. Central line placement (36555, 36556)
d. Intraosseous placement (36680)
e. Tube thoracostomy (32551)
f. Temporary transvenous pacemaker (33210)
g. Electrocardiogram - routine ECG with at least 12 leads; interpretation and report only (93010)
h. This is not an exhaustive list of possible separately billable procedures, but only serves as an example that could
be report.
11. What is the appropriate use of modifier -25 when billing for critical care services and separately billable services
or procedures? CPT does not require the use of modifier -25 when billing for critical care services and separately
billable (i.e., non-bundled) procedures. However, critical care services provided to a patient may not be paid by
some payers (e.g., Medicare) on the same day the physician also bills a non-bundled procedure code(s) unless
critical care is billed with the CPT modifier -25 to indicate that the critical care is "a significant, separately identifiable
E/M service above and beyond the other service provided or beyond the usual preoperative care associated with the
procedure that was performed." For such payers, when services such as endotracheal intubation (CPT code 31500)
and CPR (CPT code 92950) are provided, separate payment may be made for critical care in addition to these
services, if the critical care was a significant separately identifiable service and it was reported with modifier -25. The
Prepared by: Suzanne Forrest, 619-471-9154, sforrest@ucsd.edu
Date issued: 02/12/2012
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time spent performing the pre, intra, and post procedure work of these unbundled services is excluded from the
determination of the time spent providing critical care.
12. Ventilator Management & Critical Care Services: Not billable on the same day! Medicare recognizes the ventilator
codes (CPT codes 94002 - 94004, 94660 and 94662) as physician services payable under the physician fee schedule.
Medicare Part B under the physician fee schedule does not pay for ventilator management services in addition to an
E/M service (e.g., critical care services, CPT codes 99291 - 99292) on the same day for the patient even when the
E/M service is billed with CPT modifier -25.
13. Can both CPR and critical care be reported for the same patient encounter? Yes, as long as the respective
requirements for each service are satisfied and evident from the medical record. Both AMA CPT and Medicare agree
on this point.
a. CPR is a non-E/M service encompassing such activities as supervising or performing chest compressions,
adequate ventilation of the patient (e.g., bag-valve-mask), etc. CPT does not list a typical time to qualify for
providing CPR. As a separately reportable service with critical care, the time spent providing CPR cannot be
counted toward calculating total critical care time.
b. Critical care is an E/M service encompassing time spent in work directly related to care of the individual
patient's critical illness/injury, 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. Also, when the patient is unable or clinically incompetent 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.
Critical Care is a time-dependent E/M service. If the minimum total time requirement is not satisfied and/or
documented, then an appropriate other E/M code should be reported. Of course, any site of service, and
key components (i.e., history, physical examination, and medical decision making, etc.) criteria for such
alternative E/M will have to be satisfied and documented.
c. Some payers require that modifier -25 be appended to the critical care E/M or alternative E/M code in order
to indicate that it is a separately identifiable E/M service.
14. Can time spent in Family Counseling / Discussion be included in critical care time? It depends. Routine daily
updates to family members are considered part of critical care services and not separately billable. However, time
spent with family member or other surrogate decision makers may be counted toward critical care time when these
criteria are met:
a. The patient is unable or clinically incompetent to participate in giving a history and/or decision making; and
b. The discussion is necessary for determining treatment decisions
c. A summary of any family discussion is to be documented within the medical record and should include that
the patient was unable or incompetent to participate and the necessity of the discussion and any treatment
decisions made, e.g., "no other source was available to obtain a history" or "because the patient was
deteriorating so rapidly I needed to immediately discuss treatment options with the family".
d. Telephone calls to family members and/or surrogate decision makers may be counted provided that they
meet the same criteria as described above.
e. All other family discussions, no matter how lengthy, may not be counted towards critical care time.
Prepared by: Suzanne Forrest, 619-471-9154, sforrest@ucsd.edu
Date issued: 02/12/2012
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Compliance Program
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15. What are the performance and documentation requirements for use of the critical care service codes with regard
to Medicare's “split / shared service” rules for services involving physicians practicing with qualified non-physician
practitioners (NPP) (e.g., physician assistants and nurse practitioners who are eligible for professional fee billing)?
A split/shared E/M service performed by a physician and a qualified NPP of the same group practice cannot be
reported as a critical care service. Critical care codes shall reflect the evaluation, treatment and management of a
patient by an individual physician or qualified NPP and shall not be representative of a combined service between a
physician and a qualified NPP. When CPT code time requirements for both 99291 and 99292 and critical care criteria
are met for a medically necessary visit by a qualified NPP, the service shall be billed using the NPP’s appropriate
individual NPI number. The provision of critical care services must be within the scope of practice and licensure
requirements for the State in which the qualified NPP practices and provides the service(s). Collaboration, physician
supervision and billing requirements must also be met. A physician assistant shall meet the general physician
supervision requirements.
16. Global Surgery: How is critical care billing handled during the post-op period, e.g., surgery with global surgery
days? Critical care services shall not be paid on the same calendar date the physician also reports a procedure code
with a global surgical period unless the critical care is billed with CPT modifier -25 to indicate that the critical care is
a significant, separately identifiable evaluation and management service that is above and beyond the usual pre and
post-operative care associated with the procedure that is performed. This policy applies to any procedure with a 0,
10 or 90 day global period.
17. Global Surgery: Medicare Rules for Critical Care Services provided during the Pre-Op & Post-Op portion of global
period of procedure with 90 day global period in Trauma & Burn Cases.
a. Pre-op period. Preoperative critical care may be paid in addition to a global fee if the patient is critically ill
and requires the full attention of the physician, and the critical care is unrelated to the specific anatomic
injury or general surgical procedure performed. Such patients may meet the definition of being critically ill
and criteria for conditions where there is a high probability of imminent or life threatening deterioration in
the patient’s condition. Preoperatively, in order for these services to be paid, two reporting requirements
must be met. Codes 99291 - 99292 and modifier -25 (significant, separately identifiable evaluation and
management services by the same physician on the day of the procedure) must be used, and documentation
identifying that the critical care was unrelated to the specific anatomic injury or general surgical procedure
performed shall be submitted. An ICD-9-CM code in the range 800.0 through 959.9 (except 930.0 – 939.9),
which clearly indicates that the critical care was unrelated to the surgery, is acceptable documentation.
b. Post-operative period. Postoperatively, in order for critical care services to be paid, two reporting
requirements must be met. Codes 99291 - 99292 and modifier -24 (unrelated evaluation and management
service by the same physician during a postoperative period) must be used, and documentation that the
critical care was unrelated to the specific anatomic injury or general surgical procedure performed must be
submitted. An ICD-9-CM code in the range 800.0 through 959.9 (except 930.0 – 939.9), which clearly
indicates that the critical care was unrelated to the surgery, is acceptable documentation.
18. How are units of service calculated for critical care time? The following table illustrates how units of critical care
service are determined.
a. 99291 = 1st hour of critical care services (30 min to 1 hr 14 min)
b. 99292 = each additional 30 minutes of critical care services
c. Note: Consult the CPT book for applicable codes for critical care services provided to neonates, infants and
children.
Prepared by: Suzanne Forrest, 619-471-9154, sforrest@ucsd.edu
Date issued: 02/12/2012
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Compliance Program
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Time Unit
CPT Code
Less than 30 minutes
Choose the appropriate E/M code, e.g., 99231-99233
30 – 74 minutes (30 min - 1 hr 14 min)
99291
75 – 104 minutes (1 hr 15 min - 1 hr 44 min)
99291 (1 unit) + 99292 (1 unit)
105 – 134 minutes (1 hr 45 min - 2 hrs 14 min)
99291 (1 unit) + 99292 (2 units)
135 – 164 minutes (2 hr 15 min - 2 hrs 44 min)
99291 (1 unit) + 99292 (3 units)
References:

CMS Manual System, Pub 100-04 Medicare Claims Processing, Transmittal 1548, issued: 7/9/2008, Change Request
5993. Subject: “Critical Care Visits & Neonatal Intensive Care (Codes 99291 – 99292)”,
http://www.cms.hhs.gov/Transmittals/Downloads/R1548CP.pdf

CMS MLN Matters Number: MM5993, Effective date: 7/1/2008, “Critical Care Visits & Neonatal Intensive Care
(Codes 99291 – 99292)”, http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5993.pdf

CMS Medicare Claims Processing Manual, 100-4, Chapter 12, Physicians / Nonphysician Practitioners, Section
30.6.12 – Critical Care Visits & Neonatal Intensive Care (Codes 99291 – 99292),
https://www.cms.gov/manuals/downloads/clm104c12.pdf

Palmetto J1 Part B, “Critical Care & Global Surgery Package”,
http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Jurisdiction%201%20Part%20B~Articles~
EM%20Help~8DHTBR8657?open&navmenu=Articles%7C%7C%7C%7C [California Medicare MAC]
Prepared by: Suzanne Forrest, 619-471-9154, sforrest@ucsd.edu
Date issued: 02/12/2012
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