Critical Care to Home - Facility
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Defines when critical care services billed from facility/emergency department are reimbursable or non-reimbursable, focusing on claims where members are discharged to home and the coding combinations that will be denied.
No material clinical or coverage changes in this revision.
Coverage Criteria
Critical care ED billing rules
Coverage is conditional based on patient disposition and claim coding combinations.
Non-reimbursable scenarios
- CPT 99291 billed with emergency room revenue code 045X on the same line and discharge status is home (01).
Follow applicable provider, state, federal, and contract requirements which may supersede this policy.
Coding and Time Definitions
| 99291 | Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes; non-reimbursable when billed with emergency room E/M code or revenue code (045X) and discharge status of home (01). |
| 99292 | Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes; non-reimbursable. |
| 99281-99285 | Emergency department E/M codes; presence on claim with 99291 and revenue code 045X plus discharge to home (01) triggers non-reimbursement. |
| G0380, G0384 | Alternate ED visit HCPCS codes; presence on claim with 99291 and revenue code 045X plus discharge to home (01) triggers non-reimbursement. |
| 045X | Emergency room revenue code referenced in non-reimbursable scenarios. |
Provider Actions and Billing Rules
Do not bill 99291/99292 with ER revenue code 045X when discharged home (01)
Do not bill CPT 99291 (and 99292) on the same line with emergency room revenue code 045X when the member's discharge status is home (01); such critical care lines will be non-reimbursable. Also, if 99291 is billed with revenue code 045X on the same line and any ED E/M code (99281-99285 or G0380/G0384) appears on any other line with discharge status home (01), then 99291 is non-reimbursable. Follow applicable provider, state, federal, and contract requirements which may supersede this policy.
- Includes 99292 (additional critical care time) as listed non-reimbursable when associated with these non-reimbursable scenarios.
- Ensure claims meet authorization and medical necessity guidelines and use proper CPT/HCPCS/revenue coding; failure to follow coding/billing guidelines may result in denial, rejection, or recoupment.
Definitions
Admission Criteria
Admission criteria — facility
Discharge Criteria
When critical care is provided in the emergency department, reimbursement depends on patient disposition and claim coding. Critical care services are reimbursable when the patient has impairment of one or more vital organ systems with an increased risk of rapid or imminent deterioration and the member is admitted or transferred for continued monitoring. Conversely, critical care provided in the ED is non‑reimbursable if the member is discharged home (discharge status 01), because continued monitoring is not occurring.
Specific billing combinations trigger nonpayment: if CPT 99291 is billed with revenue code 045X on the same line and the discharge status is home (01), the critical care line will be non‑reimbursable. The line is also non‑reimbursable when 99291 with revenue code 045X appears on the same line and any ED E/M code (99281–99285 or G0380/G0384) is billed on any other line with discharge status home (01).
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