Medicare critical care billing and Medical necessity requirment

Critical Care Services

99291: Critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 minutes

99292: Critical care, each additional 30 minutes (List separately in addition to code for primary services)

Definition

Critical care is defined as the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. 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 ” .

Medical Necessity

Critical care services include the treatment of vital organ failure and/or the prevention of further life threatening deterioration in a patient ’ s condition. Delivering critical care in a moment of crisis, or upon being called to the patient ’ s bedside emergently, is not the only requirement for providing critical care service. Treatment and management of a patient ’ s condition in the threat of imminent deterioration while not necessarily emergent, is also required.

The presence of a patient in an ICU or CCU, or the patient ’ s use of a ventilator, is not sufficient to warrant billing critical care services. The service must be medically necessary and meet the definition of critical care. Medically reasonable and necessary services that do not meet all the criteria to report critical care should be reported with the appropriate evaluation and management code (e.g., CPT codes 99231-99233).