cpt 99291

CPT Code 99291 – Description, Billing Guidelines & Clinical Examples

This article will define CPT Code 99291, explain the medical necessity to report CPT 99291, the guidelines and clinical examples of CPT 99291.

CPT Code 99291 Description

CPT Code 99291 is defined by the CPT manual as follows (the text in Italic is the official definition of CPT 99291):

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

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 CPT 99291

Hospitals often encounter patients who are or may be seriously ill. The greatest 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, respectively, per average payment nationality of Medicare), 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 taken to provide care.

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

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:

Guidelines For Use CPT 99291 & 99292

To resolve that the provision of critical care services in lieu of other evaluation and management (E / M) services is 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 the direct personal management from a physician. They are life support and organ interventions that need continual and personal evaluation, as well as redirection by the physician.

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

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

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

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 system or to avoid further deterioration.
  • 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.

CPT Code 99291 Examples

Example 1

First hour of critical care of a 65-year-old man with septic shock following relief of ureteral obstruction caused by a stone.

Example 2

First hour of critical care a 15-year-old with acute respiratory failure from asthma

Example 3

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.

Example 4

First hour of critical care of a 65-year-old women who, following a hysterectomy, suffered a cardiac arrest associated with a pulmonary embolus.

Example 5

First hour of critical care of a 6-month-old with hypovolemic shock secondary to diarrhea and dehydration

Example 6

First hour critical of a 3-year-old with respiratory failure secondary to pneumocystis carinii pneumonia

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