CurrentBlue KCPolicy POL-PP-192

Critical Care Services

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This payment policy defines when and how critical care services (CPT 99291, 99292) are reported and reimbursed by Blue KC, including time reporting rules, services included in critical care, split/shared visits, and scenarios that may not qualify; it applies to professional providers across Blue KC lines of business.

Policy Summary

PayerBlue KC

PolicyCritical Care Services

Policy CodePolicy POL-PP-192

Change TypeNo material change

Effective DateSep 1, 2020

Last ReviewSep 1, 2026

Next Review DateSep 1, 2026

Key ActionDocument total critical care time and ensure diagnosis supports definition of critical illness to avoid claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99291, 99292Primary CPT codes described for critical care

30-74 minTime interval for first unit

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CurrentBlue KCPolicy POL-PP-192

Critical Care Services

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Policy Summary

PayerBlue KC

PolicyCritical Care Services

Policy CodePolicy POL-PP-192

Change TypeNo material change

Effective DateSep 1, 2020

Last ReviewSep 1, 2026

Next Review DateSep 1, 2026

Key ActionDocument total critical care time and ensure diagnosis supports definition of critical illness to avoid claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99291, 99292Primary CPT codes described for critical care

30-74 minTime interval for first unit

When Critical Care Services Are Covered

Coverage criteria for critical care services

Covered when ALL of the following are met:

Provider documents that the patient has a critical illness or injury that acutely impairs one or more vital organ systems with a high probability of imminent or life‑threatening deterioration.

The treatment being provided meets critical care requirements (treatment to prevent further deterioration of vital organ failures or related conditions such as central nervous system failure, circulatory failure, shock, renal/hepatic/metabolic/respiratory failure, post‑operative complications, or overwhelming infection).

Total critical care time is documented; time need not be continuous and includes direct bedside care, reviewing test results, discussion with consultants or family, and charting; excludes time off‑unit or activities not directly contributing to patient treatment and excludes time performing separately reportable procedures.

Time thresholds for billing are met per Blue KC time reporting: 30–74 minutes = CPT 99291 for the first unit; additional 30‑minute increments are reported with CPT 99292 as described in the Blue KC time matrix (examples compare CPT and Medicare intervals).

Services that are considered inclusive to critical care codes are not billed separately (examples: interpretation of cardiac output measurements, chest x‑rays, pulse oximetry, blood gases, collection and interpretation of physiologic data, computer data such as ECGs, gastric intubation, vascular access, ventilation management).

Documentation supports that the clinical scenario is not one of the scenarios that typically do not qualify (e.g., routine postoperative ICU care without additional ICU needs, patients under palliative care, ICU patients who do not meet critical care criteria, or total critical care time less than 30 minutes).

When applicable, split/shared services meet Blue KC requirements: the billing practitioner performed the substantive portion (>50% of total time) and documentation identifies both practitioners and the billing practitioner’s signature and date as required.

Claims include diagnoses that support the medical necessity of critical care; claims with diagnoses that do not support the definition of critical care may be denied for review.

Codes and Time Reporting for Critical Care

Critical care CPT codesCPTCovered

99291	Critical care, evaluation, and management of the critically ill or critically injured patient; first 30-74 minutes.
99292	Critical care, evaluation, and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service).

mixed

No codes listed

Time thresholds for units

First unit (99291)30–74 minutes (Blue KC time reporting)

Additional units (99292)Each additional 30‑minute increment reported with 99292 per Blue KC matrix

Difference vs MedicareBlue KC adheres to its own matrix; examples: Blue KC 30–74 min = 99291 while Medicare 30–103 min = 99291

Multi‑unit examples75–104 min = 99291 + 99292 x1; 105–134 min = 99291 + 99292 x2; 135–164 min = 99291 + 99292 x3 (Blue KC intervals)

Documentation, Prior Review, and Denial Risk Guidance

Denial Risk

Prior review and denial risks for critical care claims

Claims lacking a diagnosis that supports the definition of critical care are at risk for denial and may be selected for review. Additionally, certain scenarios commonly do not qualify for critical care billing (e.g., routine post‑operative ICU care included in the surgical global package; patients admitted to palliative care; ICU patients who do not meet critical care criteria; total critical care time under 30 minutes). Critical care provided in the ED that results in same‑day discharge is unlikely to meet the definition of critical illness, though ED and critical care services may both be reported when the patient’s condition changes after completion of the ED service.

Claims with a diagnosis not supporting critical care may be denied for review.
Post‑operative ICU care without additional ICU needs is typically not billable as critical care (included in global surgical package).
Patients under palliative care and ICU patients who do not meet critical care criteria generally do not qualify.
Critical care time under 30 minutes does not meet billing criteria.
Critical care in the ED with same‑day discharge is unlikely to meet critical illness definition; if condition changes after ED service, both ED and critical care may be reported.

Key Definitions

Critical illness or injury (definition)

Included conditionsMay include central nervous system failure, circulatory failure, shock‑like conditions, renal, hepatic, metabolic or respiratory failure, post‑operative complications, or overwhelming infection

Coverage requirementCare qualifies as critical care only if both the illness/injury and the treatment provided meet the critical care requirements

Substantive portion for split/shared visits

Substantive portion ruleThe practitioner who performs more than half (>50%) of the total time is considered to have performed the substantive portion when time is used for critical care

Time counting exampleIf NPP spends 10 minutes and physician 30 minutes (total 40), the physician billed because they performed >50% (30 of 40 minutes)

Documentation requirement