Critical care is the one E/M family where the note has to prove a number. The first 30 to 74 minutes of care for a patient whose organ systems are failing, or about to fail, are reported with 99291, and a payer will not accept the code without the total time in the record. Claims fail for two reasons: the note never establishes that the patient was critically ill, or the time it reports includes minutes that belong to a procedure or to another patient.
What this covers
- 99291 covers 30 to 74 minutes of critical care on one date and is reported once per date, even when the time is not continuous. Under 30 minutes, report a hospital E/M service such as 99232 or 99233.
- Medicare holds 99292 until 104 cumulative minutes, which is 74 plus a full 30. CPT guidance allows the first unit once total time passes 74 minutes, so the payer sets the threshold that applies.
- Time counts while the practitioner is on the floor or unit and immediately available to that patient, including reviewing results, discussing the case, documenting, and talking with family about treatment decisions.
- Separately reportable procedures pause the clock, so minutes spent on intubation, a central line, a chest tube or CPR are excluded, and bundled services such as chest x-ray interpretation, blood gases, ventilator management and vascular access cannot be billed during the critical care period.
- The OIG reviewed 92 critical care services at one hospital and found 56 that did not meet Medicare requirements, most of them for patients whose condition did not support the code.
A critical care claim rests on two facts: the patient was critically ill, and the practitioner was treating no one else for the minutes reported.Medicare requires the practitioner’s full attention for the time that is billed
Payment here runs on severity and time together. A 45 minute encounter described as acute respiratory failure with hypoxia, a noninvasive ventilation start and an escalation plan pays 99291. The same 45 minutes described as a routine ICU check pays a subsequent hospital visit, and the difference is not clinical. It is what the assessment and the time statement say.
The sections below cover the definition that has to be met first, the minute thresholds for 99291 and 99292, what counts toward the total and what stops it, the services Medicare bundles into the code, who reports 99291 when more than one practitioner is involved, and the note elements auditors look for.
The definition that has to be met before any time is billed
Medicare adopts the CPT definition: the direct delivery of medical care for a critically ill or critically injured patient. The illness or injury acutely impairs one or more vital organ systems, so there is a high probability of imminent or life threatening deterioration. Vital organ failure here includes central nervous system, circulatory, renal, hepatic, metabolic and respiratory failure, and shock.
The code also requires high complexity decision making: assessing, manipulating and supporting failing organ systems, or working to prevent further deterioration. A patient who is stable and responding to established treatment in an intensive care unit does not qualify, and neither does chronic ventilator or dialysis management running without a change in condition. Contractors list those encounters as ones where a visit from 99231 through 99233 fits better.
The time also has to be attention given to that patient and no other. Medicare states that critical care requires the practitioner’s full attention, and a practitioner who covers a second patient in the middle of the hour subtracts those minutes from the total.
Noridian’s critical care article is direct on this point: the documentation of the patient’s condition and the services rendered decides whether critical care is billed, not the unit. Admission for close nursing observation, a bed shortage that lands a patient in the ICU, or a hospital rule that puts an insulin infusion in the critical care unit does not create critical care.
30, 74 and 104: what the documented minutes buy
The time is the code. A practitioner who documents 30 to 74 minutes of critical care on a date reports 99291 once, even if the minutes were not continuous, because medically necessary time on the same date can be aggregated. A practitioner who documents 20 minutes reports a hospital E/M service instead.
| Total critical care time on the date | Medicare | CPT guidance |
|---|---|---|
| Under 30 minutes | 99232 or 99233 | 99232 or 99233 |
| 30 to 74 minutes | 99291 | 99291 |
| 75 to 103 minutes | 99291 | 99291 plus one 99292 |
| 104 to 133 minutes | 99291 plus one 99292 | 99291 plus one 99292 |
| 134 to 163 minutes | 99291 plus two 99292 | 99291 plus two 99292 |
The 75 to 103 minute row is where practices lose claims. CPT starts the first unit of 99292 when total time passes 74 minutes, while Medicare began requiring the full additional 30 minutes in 2023, so 90 documented minutes pay as 99291 alone on a Medicare claim. The payer policy controls.
Crossing midnight is its own rule. A continuous service that runs through midnight is reported on the date it began, with all of the time assigned there. If the service is interrupted, the later time becomes a new initial service, which can mean a second 99291 on the second date.
99291 is reported once per date per patient by a practitioner, or by a group of practitioners in the same specialty. Additional time goes on 99292, never on a second unit of 99291.
What counts toward the total and what stops the clock
CPT counts time spent in work directly related to that patient’s care, at the immediate bedside or elsewhere on the floor or unit, as long as the practitioner was immediately available. The activities behind a documented hour are broader than most notes suggest.
- Bedside assessment and management of the failing organ system
- Reviewing results for that patient that are not separately reportable, such as labs, gases and imaging
- Discussing the case with staff, consultants and the surgeon of record
- Speaking with family or a surrogate about a treatment decision when the patient cannot participate, including calls that meet the same test and are documented
- Writing the note and the orders
Two kinds of time come out of the total. Minutes spent on a separately reportable procedure belong to that procedure, and time off the unit does not count, because the practitioner is not immediately available while sitting elsewhere in the hospital or on a call from home.
On a claim that also reports endotracheal intubation (31500), central line placement (36556) or CPR (92950), the note should show the critical care total with the procedure minutes removed. A total that quietly absorbs twenty minutes of line placement is a documentation error an auditor can measure.
A total that includes off unit time is overstated, and a total with no supporting activity list is unsupported. The fix is a time statement that says where the minutes went, not a longer note.
Bundled services and the procedures that bill separately
CPT bundles a fixed set of services into critical care, and Medicare adopted the same list. During the critical care period, those services cannot be reported separately by the same practitioner.
| Bundled into critical care | Example codes |
|---|---|
| Interpretation of cardiac output measurements | 93598 |
| Chest x ray, professional component | 71045, 71046 |
| Pulse oximetry | 94760 to 94762 |
| Blood gases and physiologic data such as ECGs, blood pressures and hematologic data | Included, not separately billable |
| Gastric intubation | 43752, 43753 |
| Temporary transcutaneous pacing | 92953 |
| Ventilator management | 94002 to 94004, 94660 |
| Vascular access procedures | 36000, 36410, 36415, 36591, 36600 |
The bundle stops at central venous access. Central line placement (36555, 36556), intraosseous placement (36680), endotracheal intubation (31500), tube thoracostomy (32551), CPR (92950) and a 12 lead ECG interpretation and report (93010) are separately reportable, and the minutes spent on them are excluded from the critical care total. Coders who work medical coding problems see the two rules misfiled in both directions: a bundled chest x-ray billed alone, and a central line absorbed into the time.
Two modifiers turn up on these claims. When a same-day E/M visit and critical care are both reported, Medicare requires modifier 25 on the claim and documentation that the E/M visit came first, at a time when the patient did not need critical care, with no duplicated elements. Critical care unrelated to a procedure with a global period takes modifier FT, and a full transfer of care from a surgeon to an intensivist is shown with 54 and 55.
Concurrent care, same-day visits and split or shared time
How many practitioners can report 99291 for one patient on one date depends on specialty and group. Different specialties may each report 99291 and any 99292 units when each is managing a critical illness specific to that specialty and the work is not duplicative. Same specialty in the same group is different: the group reports one 99291 for the date, and the other practitioners report their time as 99292.
Aggregation covers the short first visit. When the practitioner who starts the service does not reach 30 minutes, a colleague in the same specialty and group can continue the care, and the group adds the two times to bill 99291 once. Past the 104 minute mark, each additional full 30 minutes supports another unit of 99292.
A physician and a nurse practitioner or physician assistant in the same group may split the service. The group sums the cumulative time, the practitioner who spent more than half of it reports the codes with modifier FS, and time the two spent together is counted once. Different specialties that both sign the note cannot use the split rule; each practitioner’s time is that practitioner’s claim.
Time a resident spends alone does not count toward critical care time. The teaching physician’s entry has to state the total time personally spent, that the patient was critically ill at that encounter, what made the patient critically ill, and the treatment and management provided. Noridian treats an entry such as “I saw the patient and agree with the resident” as unacceptable.
The documentation that survives review
Reviewers work from the note. Medicare requires the total time furnished by each reporting practitioner, and while the manual does not require start and stop times, contractors prefer them. Either format works. From there, the note has to carry the clinical argument.
- Total critical care time for that practitioner on that date, in minutes or as start and stop times
- The organ system or systems acutely impaired, with the findings that show the impairment
- Why deterioration was imminent without the interventions that were ordered
- What was done during the reported minutes, described so it can be separated from procedures
- The earlier E/M visit and the reason it did not overlap, when two services are reported on the same date
- Each contributing practitioner’s own time and role when the service is shared or split
- A statement that time spent on separately billed procedures is excluded from the total
The OIG’s 2022 audit of Lahey Clinic reviewed 92 critical care services and found 56 that did not comply with Medicare billing requirements. Of those, 54 were for patients whose condition did not indicate that critical care was medically necessary, or where the physician did not provide services at the level the code requires. The same office reported a 2018 Medicare improper payment error rate for critical care of 19.7 percent, about $198 million.
A note that reads “ICU, critically ill, 45 minutes” supplies a number and nothing else. An auditor cannot see which organ system was failing, what was done about it, or why the next hour was dangerous. For practices with a hospital census, critical care revenue cycle management comes down to the note, because the assessment decides the code.
A pre-bill check for critical care claims
List the minutes at the bedside, on the unit discussing the case, reviewing results and writing the note. Remove every minute that belongs to a procedure or was spent away from the unit.
Write the failing or threatened system and the finding behind it, such as rising lactate on vasopressor support, or hypoxia that needed noninvasive ventilation.
Put the expected deterioration in the same paragraph as the interventions, so the medical necessity of the code and the treatment read together.
Same specialty and same group means one 99291 for the date. Different specialties bill their own units when the work does not duplicate. A shared physician and NPP service carries modifier FS.
30 minutes for 99291, 104 cumulative minutes before the first Medicare 99292. A total at 90 minutes pays 99291 alone, so a note padded toward a rounder number buys nothing.
Confirm that no bundled service was billed during the critical care period, and that modifier 25 or FT is on the claim where the rules call for it.
A monthly sample of ten critical care notes answers the question faster than any dashboard. Pull the notes with the highest 99292 volume, read them against the definition and the exclusion list, and the pattern usually shows up in the first pass. A medical coding and billing review of that sample is cheaper than the recoupment it prevents.
Critical care coding questions we get every week
At least 30 minutes on the date of service, documented by the practitioner who reports the code. The code covers 30 to 74 minutes and is reported once per date, even when the time is not continuous. Fewer than 30 minutes of critical care is reported with a hospital E/M code such as 99232 or 99233.
Not for Medicare. CPT guidance allows the first unit of 99292 once total time passes 74 minutes, so a 90 minute service is 99291 plus one 99292 under CPT. Medicare requires a full additional 30 minutes, which means 104 cumulative minutes before the first unit. Follow the payer rule for the patient in front of you.
No. Time spent on a separately reportable procedure is excluded from the critical care total, so the minutes used for central line placement, intubation, a chest tube or CPR come out of the count. The procedure is billed on its own line, and the note should show its minutes were removed.
Yes when they are in different specialties, each managing a critical illness specific to that specialty, and the services do not duplicate each other. Physicians in the same specialty and same group are treated as one practitioner: the group reports 99291 for the date, and the others report their time as 99292.
No. Critical care requires acute impairment of one or more vital organ systems with a high probability of imminent or life threatening deterioration. A patient who is stable and responding to established treatment in an intensive care unit is reported with a subsequent hospital care code. The documented condition decides the code, not the unit.
The total time the practitioner spent in critical care on that date, in minutes or as start and stop times. Medicare’s manual does not require start and stop times, and contractors prefer them. The note also needs the organ system failure, the high complexity decision making, and the management provided.
The bottom line
Critical care pays for attention and severity, and the note is the only evidence of both. Put the definition in the assessment, keep procedure minutes out of the total, and the threshold arithmetic takes care of itself. A quarterly sample of critical care notes tells you which of those habits are already in place and which are still costing claims.
Are your critical care notes paying at the level they should?
We read ICU and emergency department documentation against the critical care definition, the bundled service list and the payer time thresholds, then rebuild the coding rules that keep 99291 and 99292 defensible on review. Send one week of critical care notes with the matching remittances and we will show you what is being underpaid and what is exposed.
Request a free critical care coding reviewThis article covers general coding and documentation practice rather than legal or coverage advice; payer policies and time thresholds vary, so confirm the rule that applies to the claim in front of you.
