Critical Care

HMSA medical plans cover critical care of seriously ill patients involving prolonged and direct treatment by a physician of a critically ill patient – when the physician is in constant attendance for the entire period of time (e.g., cardiac arrest, shock, bleeding or respiratory failure).

Critical care is usually, but not always, provided in a critical care area (e.g., coronary care unit, intensive care unit, emergency room).

Services Included in Critical Care

Critical care should be billed using the all-inclusive CPT codes of 99291 (for the first hour) and 99292 (for each subsequent 30 minutes). Services that are inclusive to critical care should not be billed separately. These services include, but are not limited to, the following:

• Overall evaluation of the patient’s condition. (If a significant, separately identifiable evaluation is done in addition to critical care, the physician may bill the evaluation separately using the appropriate E/M code followed by modifier 25. However, the time spent doing the evaluation should not be included in the total time calculated for the critical care codes.)
• Placement of catheters or gastric intubation
• Pulse oximetry
• The interpretation of cardiac output measures and chest X-rays
• Ventilator management
• Blood gas interpretations and analysis of information stored in computers (e.g., ECG)
• Temporary transcutaneous pacing
• Emergency room visit or hospital visit on the same day. (If a significant, separately identifiable evaluation is done in addition to critical care, the physician may bill the evaluation separately using the appropriate E/M code followed by modifier 25. However, the time spent doing the evaluation should not be included in the total time calculated for the critical care codes.)
• Services on Sundays and holidays, after office hours or between 10 p.m. and 8 a.m.

Services Not Included in Critical Care

The following services are not included in critical care, but should not be billed separately:

• Standby time awaiting diagnostic laboratory and X-ray results
• Detention time when the patient’s condition has stabilized, but the physician has made a decision to remain in attendance
• Services rendered to a patient who is in a critical care unit (e.g., intensive care) but is not critically ill as defined in the following clinical indications
• Physician’s travel time to the facility

Clinical Indications

Benefits for critical care rendered to adult patients are based on, but not limited to, the following clinical indications:

• Sustained hypotension with systolic blood pressure of less than 90 that requires aggressive treatment with pressers or fluid (shock)
• Acute bleeding with documented serious cardiovascular instability requiring emergency transfusion
• Cardiac decompensation with evidence of severe heart failure requiring use of supplemental oxygen, emergency placement of arterial or venous monitoring catheters, and aggressive intervention with medication
• Recurrent ventricular tachycardia or fibrillation unresponsive to lidocaine bolus and drip
• Respiratory failure requiring mechanical ventilation either by mask or ventilator for 15 minutes or longer

Critical care payment will not be made for patients with non-critical conditions (e.g., as migraine, sinusitis or cystitis).

Claims Filing Information

Benefits for the provision of critical care are based on the time the physician spends in constant attendance with the patient. This time is gauged from the moment the physician arrives at the patient’s bedside to the time the patient’s condition stabilizes or another physician assumes primary care of the patient.

Documentation is not required for most critical care claims, but HMSA reserves the right to request documentation should there be any question about the appropriateness of critical care in a specific situation.

Critical care should be indicated using the following procedure codes:

Note: Critical care codes are time based. When billing for critical care, the physician's documentation should include beginning and ending times for each patient encounter. The codes billed should reflect the total time spent with the patient on a single day. For example if a physician spends two hours stabilizing a patient in the morning and is called back to the unit for another hour later in the day because the patient has destabilized, the physician can bill for a total of three hours' critical care, even though the care was not continuous.

Revision History