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Only count critical care time once when multiple staff are involved

APCs Weekly Monitor, April 6, 2007

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QUESTION: We are having a difficult time ascertaining a timeframe to support hospital critical care services--i.e., how to properly report 99291 (critical care, first 30-74 minutes) and 99292 (critical care, each additional 30 minutes). Do you have any advice or guidelines you can share?

ANSWER: CMS provided guidance on counting critical care time in Transmittal 1139 (January 2007 OPPS Update). It stated the following:

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 critically injured patient. 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.   

CMS reiterated this statement in a recently-released document, "OPPS Visit Codes Frequently Asked Questions," which you can find at the CMS Web site.

CMS also provided the following information on payment for critical care services in the FAQ:

Q: Under the OPPS, how does CMS pay for critical care services?

A: When a minimum of 30 minutes of critical care services are provided in a hospital outpatient setting, the hospital must report CPT code 99291, Critical care evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We provide packaged payment for CPT code 99292, Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes, for those periods of critical care services extending beyond 74 minutes, so hospitals do not have the ongoing administrative burden of precisely reporting the time for the complete period of critical care services provided.

When at least 30 minutes of critical care is provided, the hospital will bill CPT code 99291 (and 99292, if appropriate), and receive payment for APC 0617, 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.

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