ED Coding and Reimbursement Alert

Question: Our physician provided 100 minutes of critical care to a patient having a stroke. This encounter did not take place in the critical care unit, however. The physician treated the patient in an observation unit. Can I still report critical care for this session?


Texas Subscriber

Answer: Yes, you can report critical care codes for this service. On the claim,

- report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the first 74 minutes of critical care.

- report +99292 (... each additional 30 minutes [list separately in addition to code for primary service]) for the ensuing 26 minutes of critical care.

- attach 434.90 (Cerebral artery occlusion, unspecified; without mention of cerebral infarction) to 99291 and 99292 to represent the patient's stroke.

Explanation: When you-re deciding whether or not your ED physician provided critical care, it is the patient's condition, not the place of service, that determines whether you can report 99291-99292. Typically, the ED physician will provide a 99291 service in the ED.  However, she can also perform critical care in the observation unit, or the medical surgical floor, or anywhere else that she tends to a critically ill patient.

Remember that your documentation must prove that  the patient was critically ill and that minimum time thresholds were met. Also, keep in mind that 99292 is an add-on code, meaning that you cannot report it without also reporting 99291.