Critical Care is Critical to the OIG: Know the Requirements

In 2019, Office of Inspector General (“OIG”) added the review of critical care evaluation and management codes to their work plan for the Office of Audit Services. This review will determine whether Medicare payments for critical care codes (99291-99292) are appropriate and paid in accordance with Medicare requirements.¹ The core requirements for critical care coding are medical necessity, physician actions, time, and documentation.

Key Points for Critical Care Coding:

• Time of 30 minutes or greater MUST be documented. Keep in mind that specifying a time is a requirement for billing critical care, but critical care cannot be billed simply because time is documented for a visit in a critical care area of the facility (i.e. emergency room or ICU).
• Critically ill does not always mean critical care. Documentation must also support physician intervention. Intervention is defined as an action taken to improve a situation, especially a medical disorder (I.e. medical management, cardiopulmonary resuscitation, decision for emergency surgery, etc.).

Note that several conditions could eventually result in death or impairment (i.e. DVT) without treatment (i.e. anticoagulation). Critical care services are for treatment of conditions or complications that could result in immediate death or patient impairment during that visit (i.e. intervention for cardiac arrest due to pulmonary embolism).

Critical care does not always happen upon arrival to the facility. If a patient is admitted with respiratory distress, critical care is provided, and the patient stabilizes but becomes hypotensive or returns to severe respiratory distress on the 3^rd day of admission, critical care services may be warranted once again.

Some services are bundled into critical codes 99291 and 99292. These services include:

• Interpretation of cardiac output measurements
• Chest X-rays
• Pulse oximetry
• Blood gases and information data stored in computers (e.g., ECGs, blood pressures, hematologic data)
• Gastric intubation
• Temporary transcutaneous pacing
• Ventilator management
• Vascular access procedures

Always check NCCI edits. Most services, such as cardiopulmonary resuscitation, are separately reportable.

What are the time requirements for critical care?

Code 99291 is used to report the first 30-74 minutes of critical care on a given date. It should be used only once per date, even if the time spent by the individual is not continuous on that date. Critical care of less than 30 minutes total duration on a given date should be reported with the appropriate E/M code.

Code 99292 is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes.

• Less than 30 minutes – appropriate E/M code
• 30-74 minutes – 99291 x1
• 75-104 minutes – 99291 x1 AND 99292 x1

(See current CPT book for further examples)

CMS has provided examples of patients whose condition may warrant critical care services²:

• An 81-year-old male patient is admitted to the intensive care unit following abdominal aortic aneurysm resection. Two days after surgery he requires fluids and pressors to maintain adequate perfusion and arterial pressures. He remains ventilator dependent.
• A 68-year-old admitted for an acute anterior wall myocardial infarction continues to have symptomatic ventricular tachycardia that is marginally responsive to antiarrhythmic therapy.
• A 67-year-old female patient is 3 days status post mitral valve repair. She develops petechiae, hypotension and hypoxia, requiring respiratory and circulatory support.

CMS has also provided examples of patients whose condition may NOT warrant critical care services or may not satisfy the requirements for critical care services²:

• Daily management of a patient on chronic ventilator therapy does not meet the criteria for critical care unless the critical care is separately identifiable from the chronic long-term management of the ventilator dependence.
• Patients admitted to a critical care unit because no other hospital beds were available

¹https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000316.asp

²CMS Claims Processing Manual Transmittal 2997 (January 25, 2014)