Medicaid hospital Reimbursement

CPT Code 99291 & CPT Code 99292 Reimbursement

Critical care is the care and monitoring of unstable critically ill or injured patients in a variety of medical emergencies that require constant attention that can only be provided by a physician. The care of such patients involves decision-making of such high complexity to assess, manipulate, and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, unpredictable postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple vital organ system failure or to prevent further deterioration. It may require extensive interpretation of multiple databases and the application of advanced technology to manage the patient. Critical care may be provided on multiple days provided that the condition requires the level of physician attention as described above.

Examples can include cardiac arrest, shock, severe bleeding, respiratory failure, and postoperative complications that are not an expected complication of the initial illness, injury, diagnosis or surgical procedure.

Critical care is usually, but not always, provided in a critical care area such as the coronary care (CCU), intensive care (ICU), or respiratory care unit. However, critical care services may be provided in any location in unusual circumstances.

CPT codes for Critical Care visit

The critical care codes are used to report the total duration of time spent by a physician providing constant attention to an unstable patient, even if the time spent by the physician providing critical care services on that date is not

If the total time providing critical care is 30 minutes or less do not report critical care. Report the appropriate level of evaluation and management procedure code.

Procedure code 99291 is billed to report up to the first 30 – 74 minutes of critical care service per day. This procedure code may be billed only once per day by an individual physician or physician of the same specialty within a physician group

Procedure code 99291 with one (1) unit of 99292 is billed when the total critical care time is 75 -104 minutes.

For critical care services beyond a 104 minute period, physicians must bill 99291 with incremental units of 99292 according to the time chart in the CPT coding book. For services in excess of 4 units of 99292 on any date of service by an individual physician, the provider must submit additional units of 99292 with modifier 22 and attached medical documentation to support the medical necessity for the length of critical services, and the need for physician constant attention.


Reimbursement may be made under the critical care codes only if the physician is providing constant attention to the unstable critically ill patient. Services provided in a CCU or ICU that do not meet this requirement are not to be billed under the critical care codes. Hospital care evaluation and management codes should be used to report these services. All other program and CPT guidelines apply.


Critical care is considered an evaluation and management service and a number of procedures are included in the critical care codes that are not reimbursed separately when they are provided on the same day by the physician. Medicaid limits procedures that may be reimbursed on the same date of service as a critical care evaluation and management visit.

Place of Service:

Critical care is expected in the inpatient hospital setting and is only reimbursable by Medicaid when the critically ill or injured patient is either admitted to the inpatient hospital or is anticipated as an admission to the inpatient hospital for continued critical care.

Non-Critical Care:

When a recipient is still located in the critical care area of the facility, but is no longer critically ill, the provider must bill subsequent hospital visits instead of critical care.

Prolonged and Stand-By Services

Physician stand-by service and prolonged service will not be reimbursed in addition to critical care.

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