Contact Us
(855) 322-6337


Documenting & Billing Critical Care for OPPS

Documentation and billing for the hospital component of ED critical care continue to present a challenge for hospitals as the rules, based somewhat on CPT but with a twist added by the Centers for Medicare & Medicaid Services (CMS), differ enough from the professional rules to create a significant challenge. Beginning January 1, 2007, critical care services were paid at two levels depending on whether or not there is also trauma activation. Hospitals will receive one payment rate for critical care without trauma activation and will receive additional payment when critical care is associated with trauma activation.

When critical care services are provided without trauma activation, the hospital may bill CPT code 99291, Critical Care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. If additional Critical Care time is documented over 74 minutes, 99292 Critical Care would be billed for each additional 30 minutes of critical care. If trauma activation occurs under the circumstances described by the National Uniform Billing Committee (NUBC) guidelines that would permit reporting a charge, the hospital may also bill one unit of the code for trauma activation, G0390, which describes trauma activation associated with hospital critical care services. Time, intensity and content of the service form the foundation of this Evaluation and Management service.
Critical care is defined as a critical illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition. Key to understanding appropriate billing of critical care is an understanding of how a routine Evaluation and Management service makes the jump to critical care. As the CPT guidelines indicate, hospitals that provide less than 30 minutes of critical care should bill for a visit, typically an emergency department visit, at a level consistent with their own internal guidelines.
Critical care requires decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition. Examples of vital organ system failure include, but are not limited to central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure.

The time spent managing the critical patient is the key factor. For the hospital to bill the facility component of this service, documentation must support a minimum of 30 minutes of critical care service to the patient. Medicare PUB 100-94 MCP, Transmittal 1139, Dec 22, 2006 stated this 30 minute minimum has always applied under the OPPS and will continue to apply . . . CMS says that under the OPPS, the time that can be reported as critical care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or injured patient.
(Note: for billing of critical care by the EDMD, the time is NOT required to be face-to-face.) If the physician and hospital staff or multiple hospital staff members are simultaneously engaged in this active face-to-face care, the time involved can only be counted once. Thus, to assure you can code this service correctly, documentation must clearly state the start and stop times spent with the patient by each health care provider so that coding professionals can accurately count individual and group provider times accurately.

Critical care includes certain other separately identifiable procedures or services that are included in the critical care package and cannot be billed separately. These include interpretation of cardiac output measurements, chest X-rays, pulse oximetry, blood gasses, information data stored in computers, gastric intubation, temporary transcutaenous pacing, ventilatory management and vascular access procedures. (CPT provides the codes related to each of these bundled services.) Additional procedures provided during the visit are paid separately.

Critical patients often require life-saving interventions. One of the most frequent is CPR. When cardiopulmonary resuscitation is performed without other evaluation and management services, e.g., a physician responds to a code blue, directs CPR, then the patient’s attending physician resumes care of the patient), only the CPT code 92950 for CPR should be reported. The levels of critical care are determined by time so when CPT code 92950 is reported, the time required to perform CPR is not included in critical care. When both services are performed in the emergency department, both may be billed separately as long as critical care is performed for a minimum of 30 minutes in addition to performance of CPR and documented appropriately. Additional procedures provided by ED staff or consultants supported by ED staff are separately billable by the hospital as long as the time spent performing these procedures is removed from the time used to determine critical care.