(2023) CPT Code 99291 & 99292 | Descriptions, Billing Guidelines & Clinical Examples

This article will define CPT code 99291 and add-on code CPT 99291. We will explain the medical necessity to report these codes, include some guidelines, and provide clinical examples.

Description Of The CPT Code 99291

The official description of the 99291 CPT code is: “Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes”

Reporting CPT code 99291 is a prerequisite to reporting CPT code 99292. Physicians of the same specialty within the same group practice bill are paid like a single physician.

The official description of the 99292 CPT code is: “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).“

The critical care CPT codes 99291 – 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous. Non-continuous time for medically necessary critical care services may be aggregated.

Critical care, evaluation, and management of the critically ill or critically injured patient; first 30-74 minutes

Reporting Critical Care

Hospitals often encounter patients who are or may be seriously ill. The most significant efforts in caring for these patients are best captured through the critical care service codes 99291 and 99292.

Although these codes generate a higher reimbursement ($20.15 and $102.50 per average payment nationality of Medicare), they are reported only in certain circumstances.

Physician records should include sufficient detail to support critical care requests: the patient’s condition, the nature of the physician’s care, and the time to provide care.

Documenting any other relevant information is highly recommended because these services are often under the payer’s control.

CPT code 99291 represents the first 60 minutes of intensive/critical care, which clinicians can report after accumulating the first 30 minutes of care.

Alternatively, the medical treatment of the patient with less than 30 minutes of intensive care time on a specific day should be reported with the corresponding evaluation and management code:

• Inpatient consultation (99251-99255)
• Subsequent hospital care (99231-99233)
• Initial inpatient service (99221-99223)

Guidelines For Use CPT 99291 & 99292

To resolve that the provision of critical care services instead of other evaluation and management (E / M) services are medically needed, the following two medical review principles must be met together with the Procedural Terminology Manual Current (CPT) definitions:

Clinical Condition Criterion: There is a high likelihood of a sudden, clinically significant, or life-threatening deterioration of a patient’s condition that requires the highest level of preparedness from a physician for urgent intervention.

Treatment Criteria: Critical care services need direct personal management from a physician. They are life support and organ interventions that need continual and personal evaluation and redirection by the physician.

Withholding or not starting these interventions urgently would likely result from a sudden, clinically significant, or life-threatening worsening of the patient’s condition.

The provision of medical care to a seriously ill patient should not unquestionably be classified as an intensive care service because the patient is seriously unwell.

To be considered covered, the provider’s service must be medically necessary and follow the rationale of intensive care services, outlined in the following points.

Definition of Intensive Care

• Intensive care is the direct provision of a healthcare practitioner to a seriously ill or injured patient.
• The care of these patients is associated with a very complex decision-making process to assess, shape, and uphold central nervous system failure, circulatory failure, shock-like conditions, overwhelming infections, metabolic or respiratory failure, renal, hepatic, postoperative complications, or other crucial systems.
• It works to treat the failure of a single or numerous vital organ systems or to avoid further deterioration.
• It may need extensive analysis of numerous databases and the operation of advanced patient management technologies.
• Intensive care services include treatment and prevention or added deterioration of central nervous system failure, circulatory failure, shock-like conditions, overwhelming infections, metabolic or respiratory failure, renal, hepatic, postoperative complications, or other crucial systems.

Billing Examples

Below are five clinical examples of cases when CPT 99291 and CPT 99292 can be billed.

Example 1

The first hour of critical care of a 65-year-old man with septic shock following relief of ureteral obstruction caused by a stone. The first hour is billed with 99291.

Example 2

Two hours of critical care, a 15-year-old with acute respiratory failure from asthma. The first hour is billed with 99291 and for the additional time, 99292 is used.

Example 3

The first hour of critical of a 45-year-old who sustained a liver laceration, cerebral hematoma, flailed chest, and pulmonary contusion after being struck by an automobile.

CPT 99291 can be used for the first hour of service.

Example 4

Two hours of critical care of a 65-year-old woman who, following a hysterectomy, suffered a cardiac arrest associated with a pulmonary embolus.

The first 72 minutes can be billed with 99291; for the rest of the time, add-on code 99292 may be billed.

Example 5

For the first hour of critical care of a 6-month-old with hypovolemic shock secondary to diarrhea and dehydration, CPT 99291 can be reported.