Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.30
    OpenPayerBilling CodesCritical Care ServicesCPT cpt-99291-critical-care-evaluation-management-30-74-minutes
    Ask Trek AI about this page

    CPT 99291: Initial Critical Care, 30–74 Minutes

    Medicare pays $318 and commercial payers pay $880 on average nationally for this procedure.

    CPT code 99291 describes an initial critical care service for patients with life‑threatening illness or injury requiring high‑intensity medical management; reporting requires documentation of severity, intensity of services, and time spent and is typically used for care delivered in an intensive care unit, coronary care unit, respiratory care unit, or emergency department when critical care is provided for 30–74 minutes.

    For related coverage guidance, see recent payer policy updates: Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure, Cardiology - Ivabradine, Cardiac Computed Tomography (CCT)/Coronary Computed Tomographic Angiography (CCTA).

    Customize your policy alerts

    Sign up for cpt 99291 policy alerts

    Get alerted when payer policies referencing 99291 are released or updated.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    National Reimbursement Benchmarks

    Across national benchmarks for CPT 99291, Medicare's mean rate of $317.6 sits well below BUCA's mean commercial benchmark of $879.9, indicating that average commercial reimbursements (as represented by BUCA) are roughly $562.3 higher than Medicare for this code. This gap highlights a substantial divergence between the federal payer baseline and aggregate commercial pricing for high-acuity critical care services.

    Examining dispersion using the interquartile spread (P75 minus P25), Blue Cross Blue Shield shows the narrowest spread of $379.2 (P75 $1,449.40 minus P25 $1,070.20), indicating relatively tighter clustering among its commercial rates. UnitedHealth Group and Cigna have wider spreads of $222.8 and $221.7 respectively, while Aetna's spread is $245.8. BUCA's spread is $315.9 (P75 $1,024.80 minus P25 $710.90). These differences reflect varying degree of rate concentration across payers.

    National Payer Mean Reimbursement Rates

    Table of contents

    Progress1 / 8

    Explore openpayer tools

    • Billing CodesCPT, HCPCS, DRG & more
    • Reimbursement RatesCommercial vs. Medicare rate reports
    • Facility ComparisonBeds, revenue & payer mix
    • ProvidersHospitals & facilities
    • PayersPlans & market footprint
    • Taxonomy CodesNUCC specialty codes
    • ModifiersCPT modifiers & usage
    • Prior AuthorizationPA policies by payer & drug
    • Timely FilingFiling deadlines by payer
    • Coverage CriteriaMedical necessity by payer
    • Payer ContactsClaims, PA & appeals contacts
    View all tools

    State Reimbursement Rates

    State: Alaska1 / 51

    Rate by payer

    Clinical & Coding Specifications

    Clinical Context

    A 68-year-old male with a history of essential hypertension (I10) is brought to the emergency department after collapsing at home. On arrival he is hypotensive and tachycardic, with altered mental status and low oxygen saturation. Initial assessment suggests possible sepsis (A41.9) with progression to acute respiratory failure (J96.00) and evolving shock (R57.9). The patient requires immediate airway management, hemodynamic support, continuous monitoring, frequent reassessments, and time-sensitive interventions in the intensive care unit.

    The clinical workflow begins in the emergency department with rapid stabilization: airway assessment, oxygenation and ventilation support (intubation if indicated), and fluid resuscitation and vasopressors for shock. Once the patient is determined to need ongoing intensive monitoring and management of life‑threatening organ dysfunction, an attending physician documents the medical necessity for critical care and initiates admission to an ICU or critical care area. The attending documents the severity of illness, the specific high‑intensity interventions (for example, initiation of mechanical ventilation or vasopressor titration), and the total time spent providing direct critical care management. For the initial 30–74 minutes of critical care performed by the reporting physician, 99291 is reported, with additional time beyond the first 74 minutes captured by 99292 in 30‑minute increments.

    Related CPT Codes

    CPT Code

    Related Modifiers

    10 rows

    ModifierDescriptionWhen to Use
    25CPT modifier 25 indicates that on the same day as another procedure or service, the same physician or other qualified health care professional provided a significant, separately identifiable…- When to apply: Use modifier 25 only on an E/M code to indicate the same provider delivered a significant, separately identifiable E/M service on the same day as another procedure or service — i.e.,…
    59Modifier 59 indicates a distinct procedural service when two procedures that are not normally billed together are clinically and procedurally separate. The CPT definition (as reiterated by CMS)…- Use modifier -59 to report a distinct procedural service when documentation supports that the procedure reported is not normally billed together with another service on the same day because of a…
    26Modifier 26 (Professional Component) identifies and bills only the professional portion of a split service — the physician’s interpretation, report, and medical judgment — when the technical…- Use CPT Modifier -26 when you are billing only the professional component (PC) of a split‑bill eligible service—i.e., you performed the physician interpretation, medical judgment and prepared a…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    76Modifier -76, Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional, is appended when the same provider performs an identical, medically necessary procedure or…- Use modifier -76 when the same physician or other qualified health care professional performs an identical procedure or service a second (or subsequent) time on the same date of service and the…
    77Modifier 77 indicates that a previously performed procedure or service was legitimately repeated by a different physician or other qualified health care professional. The AMA’s CPT definition…- Use modifier 77 when a basic procedure or service already performed is repeated by a different physician or other qualified health care professional (for example, a second provider independently…
    91Modifier 91 — “Repeat Clinical Diagnostic Laboratory Test” — is appended when the exact same CPT laboratory test is performed more than once for the same patient on the same day because serial,…- Use modifier 91 when the exact same CPT laboratory test is performed more than once on the same patient on the same date because serial or repeated testing is medically necessary to monitor…
    95Modifier 95 indicates that a service was provided via synchronous, real‑time audio‑video telehealth rather than in‑person. Per CMS, AAPC and professional associations, append modifier 95 to claim…- Use modifier 95 to indicate a service was furnished via synchronous, real‑time audiovisual telehealth (a live audio‑video conference between patient and provider) rather than in‑person. - Pair…
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…

    Related Provider Taxonomies

    8 rows

    Taxonomy Code
    207LC0200X
    207P00000X
    364SC0200X
    171WH0202X
    1835X0200X
    207L00000X
    347B00000X
    363LP1700X

    Related Payer Policy Updates

    Specialty: Cardiology1 / 3

    10 rows

    PolicyPayerEffective Date
    Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients with Elevated Office Blood PressureBluecross Idaho2026-11-01
    Cardiology - IvabradineCigna2026-10-15
    Cardiac Computed Tomography (CCT)/Coronary Computed Tomographic Angiography (CCTA)univerahealthcare2026-10-15
    Percutaneous Ventricular Assist DeviceUnitedHealthcare2026-10-01
    Cardiovascular Disease Risk AssessmentOscar Health2026-10-01
    Biomarkers for Myocardial Infarction and Chronic Heart FailureOscar Health2026-10-01
    Multiple Procedure Payment Reduction for Diagnostic Cardiovascular ProceduresBlue Cross Blue Shield - Maine2026-10-01
    Left Atrial Appendage Closure Devicesexcellus_health_plan_inc2026-09-17
    Left Atrial Appendage Closure Devicesuniverahealthcare2026-09-17
    Cardiac Omnibus CodesCigna2026-09-15

    Related Codes

    CPT-99292-CRITICAL-CARE-ADD-ON-30-MINUTE-INTERVAL

    CPT 99292: Critical care, each additional 30 minutes

    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
    Published by

    Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

    Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

    Description
    Relationship to This Procedure
    99292Critical care, each additional 30 minutesReported when total critical care time by the physician exceeds the initial 99291 interval; billed in 30‑minute increments
    31500Intubation, endotracheal, emergency procedureOften performed during early resuscitation for patients with respiratory failure prior to or during the 99291 time period; supports airway management interventions
    92950Cardiopulmonary resuscitation (CPR)Performed for cardiac arrest (I46.9) and may overlap with critical care time; document separately when applicable
    94002Ventilation assist and management, initiation of pressure or volume preset ventilators for acute respiratory failureUsed when initiating mechanical ventilation for acute respiratory failure (J96.00) and is commonly performed alongside critical care management provided under 99291.