CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Critical care coding, documentation and reimbursement

Defines what constitutes physician critical care, lists inclusive and non-inclusive activities, documentation requirements, and reimbursement rules for claims submitted to Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCritical care coding, documentation and reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionOnly one physician may bill any given hour of critical care; report 99291 once per date for 30–74 minutes and 99292 for each additional 30-minute interval beyond 74 minutes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99291 once per dateprimary critical care code rule

99292 per 30madd-on code

Ventilator, vascular access, blood gasesinclusive activities

CMS-1500 & all POSsubmission scope

When Critical Care Is Covered

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Critical care coverage criteria

Payment is provided when care meets the definition of critical care and documentation supports personal management and time spent. Certain activities are considered inclusive, some are excluded, and specific billing/time rules apply.

Care must be of a critically ill or unstable patient requiring constant physician attention.

Physician must document total critical care time (minutes) in the medical record and describe activities performed; documentation may be requested to support the claim.

Only one physician may bill for any given hour of critical care.

In teaching facilities, time spent teaching or supervising residents is not considered critical care; critical care billed by a physician cannot include delegated care by other health care professionals or residents.

Included activities (examples)

Review of medical data (labs, x-ray, or other diagnostic tests).
Discussion of the patient's care with other medical staff in the unit or at the nurse's station.
Obtaining medical history and discussion of treatment options with family/guardian when patient cannot contribute, provided the conversation directly contributes to medical decision-making.
Ventilator management and settings.
Vascular access procedures.
Review of EKGs, blood pressures, and hematologic data.
Blood draws for specimen and blood gases.
Chest x-ray review.
Interpretation of cardiac output measurement.
Family medical psychotherapy.

Activities not considered critical care

Routine family updates or emotional support conversations that do not directly contribute to medical decision-making.

Procedures listed as included with critical care (e.g., gastric intubation, pulse oximetry, temporary transcutaneous pacing) are not reimbursed separately when performed by the physician billing critical care.

If critical care is billed for an emergency department visit, no other ED or outpatient E/M codes will be reimbursed for that visit.

Time-based billing rules: 99291 is reported once per date for the first 30–74 minutes of critical care; 99292 is reported for each additional 30-minute interval beyond 74 minutes. Less than 30 minutes: report 99232 or 99233; 75–104 minutes: 99291 + 99292 x1; additional 30-minute increments add 99292 as appropriate.

Modifiers 24, 25 or 59 may be used to indicate a separately identifiable service when applicable; guideline applies to CMS-1500 claim submissions and to all places of service.

This guideline is not a guarantee of reimbursement; plan coverage, eligibility and claim payment edit rules may apply.

Codes and Time Thresholds for Billing

Critical care time codesCPTCovered

99291	First 30-74 minutes of critical care
99292	Each additional 30-minute interval beyond 74 minutes

Time thresholds for billing — minutes to code mapping

Billing for <30 minutesLess than 30 minutes: report 99232 or 99233 (not critical care codes)

Initial critical care interval30–74 minutes: report 99291 (first/initial critical care code)

First additional interval75–104 minutes: report 99291 + 99292 x1 (99292 reports one additional 30-minute interval beyond the initial period)

Additional 30-minute incrementsFor each additional 30-minute increment beyond 74 minutes, add one 99292 (e.g., 105–134 minutes = 99291 + 99292 x2)

Single-physician billing ruleOnly one physician may bill for any given hour of critical care; 99291 may be billed once per date for the first 30–74 minutes

Billing Guidance and Provider Responsibilities

Billing Rule

Billing and submission rules for critical care time

Only one physician may bill for any given hour of critical care; 99291 is reported once per date for the first 30–74 minutes of critical care, and 99292 is used to report each additional 30-minute interval beyond 74 minutes. For claim submission, use the total-duration guidance (e.g., 30–74 minutes: 99291; 75–104 minutes: 99291 + 99292 x1; additional 30-minute increments add 99292) and submit on CMS-1500 forms for all places of service.

Only one physician can bill for any given hour of critical care.
99291 billed once per date for first 30–74 minutes.
99292 reported for each additional 30-minute interval beyond 74 minutes.
Total duration examples: <30 min = 99232/99233; 30–74 min = 99291; 75–104 min = 99291 + 99292 x1, etc.
Applies to CMS-1500 claim submissions and all places of service.

Key Definitions and Inclusive Activities

Definition of critical care

DefinitionCare of a critically ill or unstable patient who requires constant physician attention; duration is the time the physician spends providing full attention to the critically ill patient.

Documentation requirementPhysician must record time spent and services rendered in the patient record to support the claim for critical care services.

Scope of paymentPayment may be made for critical care services in any location as long as the care meets the definition of critical care.

Activities considered inclusive in critical care

Examples of included procedures/activitiesVentilator management and settings; vascular access procedures; review of EKGs, blood pressures, and hematologic data; blood draws; blood gases; chest x-ray review; interpretation of cardiac output measurement; family medical psychotherapy.

Medical data reviewReview of medical data such as lab, x-ray, or other diagnostic tests is considered inclusive.

Communication that countsDiscussion of the patient's care with other medical staff and obtaining history/discussion with family that directly contributes to medical decision-making are included; routine family updates or emotional support are not.

Procedures not billed separatelyProcedures listed in the critical care service code descriptions (e.g., gastric intubation, pulse oximetry, temporary transcutaneous pacing) are not reimbursed separately when provided by the physician billing critical care.