Coding and Critical Care Billing Services

Key Points for Billing and Coding Critical Care Services

Critical care medicine specialists diagnose and treat a wide variety of diseases. A multidisciplinary team approach is needed to care for critically ill patients. Though there are only two codes for critical care services, reporting critical care presents a challenge because of the rules and regulations involved. In fact, Medicare and commercial payers scrutinize the manner in which critical care services are billed. Documentation of medical necessity is crucial. Physicians can rely on expert coding and critical care billing services to bill critical care correctly based on the documentation.

Services must be medically necessary and meet the requirements of critical care services. Care provided to patients that do not meet all of the criteria for critical care is reported using the appropriate E/M code depending on the level of service provided.

Hospital ward, nurse and patient, isolated on a white background.

Critical care is a time-based service

Time may be continuous or an aggregate of intermittent time spent by members of the same group and same specialty.

Progress notes must document the total time the critical care services were provided for each date and encounter entry. When multiple physicians are involved, the documentation must support the medical necessity of the critical care services rendered by each physician.

The time requirement of the initial critical care service must be met by only one physician or non-physician practitioner.

Same specialty:

Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician.

CPT code 99291 should be used once per calendar date per patient by the same physician or physician group of the same specialty.


Different specialty:

Physicians of a different specialty may each report CPT code 99291 if they are providing care that is unique to his/their individual medical specialty and managing at least one of the patient’s critical illness(es) or critical injury(ies)

Critical care of fewer than 30 minutes total duration on a given calendar date is not reported separately using the initial critical care CPT code (99291). This service should be reported using another appropriate E/M code [ensuring all components of the CPT descriptor are met] such as subsequent hospital care.

Avoiding Audits

When it comes to critical care services, the red flags that will attract the attention of insurance carrier auditors are inaccurate coding, insufficient or lack of documentation, nonadherence to payer policies, and lack of medical necessity. Unbundling procedures included in critical care or overuse of modifiers can also trigger an audit.