Internal Medicine Coding Alert

Question: Please do let me know if we can use critical care codes 99291-99292 in a physician’s office.

Tennessee Subscriber

Answer: You are allowed to report critical care codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (…each additional 30 minutes [List separately in addition to code for primary service]) in a physician’s office. You can use these codes irrespective of the location in which your clinician is providing these services as long as other criteria supporting the service on the claim are met. Per CPT®, “Critical care is usually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or the emergency care facility.” (Emphasis added) 

Ensure that the patient’s condition qualifies as critical and that the care provided rises to the level of critical care. CPT® guidelines state that “Critical care is the direct delivery by a physician(s) or other qualified health care professional of medical care for a critically ill or critically injured patient” and “a critical illness or injury 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.”  

CPT® goes on to state, “Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s)to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.” Finally, CPT® notes, “Providing medical care to a critically ill, injured, or postoperative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements.” 

CMS, like virtually all payers, expects that critical care services are medically necessary and reasonable when reported. If services provided are not in accordance to the definitions of critical care services, then an appropriate E/M code should be used to report the services provided.

So, report critical care codes if the patient’s condition of criticality is met and the care provided rises to that level. Otherwise, you should choose an appropriate E/M code for the visit.