Critical Care Billing and Coding Review and Updates for 2024

Kari Gorder, MD

While it may not be the most exciting topic to discuss, critical care billing and coding is an important part of our jobs. If you work as a clinician in the intensive care unit, you know how time-consuming and exhausting your days can be. Ensuring that your time and efforts are appropriately reimbursed is vital. Each hospital system handles critical care billing differently, and depending on where you work, you may be fairly removed from the actual billing process. However, other critical care providers may have to directly enter and adjudicated their own billing codes. For all of us, knowing some of the basics of billing and coding can ensure that you are compensated correctly and help avoid those pesky inbox clarification messages! Below is a brief review of critical care billing and coding, with some tips and tricks interspersed throughout. None of this is meant to supplant guidance from coding or billing professionals but may be helpful for your day-to-day documentation. Other great resources include ACEP’s critical care billing FAQ and the Society of Critical Care Medicine, which hosts a free annual webinar regarding critical care billing and coding, from which much of the following information was gleaned. This article applies only to the adult critical care patient population, as neonatal and infant critical care billing is done somewhat differently.

Documenting Medical Necessity

There currently exists a large degree of variability in the interpretation of appropriate documentation and coding for critical care services, and as such is an area of focus for payers looking to dispute charges. Knowing the definitions of critical care – and being able to succinctly document how the care you give fits these definitions – is crucial. Documenting medical necessity is the most important part of critical care billing and involves the management of any number of failing organ systems that, without immediate intervention, would have a high probability of resulting in patient deterioration or death. Many medical conditions can qualify for critical care, including cardiac arrest, cardiogenic shock, acute hepatic or renal failure, CNS disorders, or post-traumatic complications. Your documentation must clearly show why the patient is critical. Avoid blanket statements or dot phrases and instead give specifics, like what organ system is involved, what diagnostic or therapeutic interventions were performed with their rationale, and what the likelihood of deterioration is without intervention.

While critical care can be given in a moment of crisis – for example, running into a room to code a patient – this is not a requirement for providing critical care services. Critical care often requires the interpretation of multiple physiologic parameters or technologic devices but again, this is not a requirement for the delivery of critical care. Notably, critical care is not able to be billed simply based on diagnosis or location; for example, a patient in the ICU for close monitoring every hour by nursing staff may not meet the diagnostic criteria of critical care, nor would a patient who is “critically ill but stable,” such as a patient on the ventilator without any change in ventilator requirements. On the other hand, critical care can be provided on multiple subsequent days for a patient with no change in status if the condition continues to require the same level of attention of the clinician to avoid deterioration or death. The key here is documentation: it must be clear that there is active management of vital organ systems to prevent deterioration or death, and that the provider was either at the bedside or immediately available for care. Finally, critical care is not limited to the ICU – while it is most commonly delivered in that setting, it can be billed for in any environment, including the emergency department or, rarely, the floor.

Some specific scenarios that would not qualify for critical care billing include:

• Patients in the post-operative period in the ICU without any additional ICU needs other than those related to post-operative issues (this is included in the global bill for surgical procedures; more on this below)
• Patients who are admitted under palliative care, even if they are in the ICU
• Patients in the ICU who otherwise don’t meet the criteria for critical care (e.g., the q1 hour eye drop patient)
• Patients for whom you gave less than 30 minutes’ care (see below)

Critical Care is a Time-Based Code

The second most important thing to understand is that for adult patients (which, in the critical care world, is apparently 6 years old or greater), critical care is a time-based code. This means you sum up all the time you spend delivering critical care to a single patient, which may include:

• Direct critical care at the bedside (excluding procedures that are NOT bundled into the critical care billing code; see below)
• Discussing the patient with members of the care team, including consultants, APPs and nurses
• Reviewing data related to the patient
• Writing notes in the chart when on the unit and immediately available to the patient
• Discussions with family members, but only if the patient is unable to participate in their care or if it involves obtaining a clinically-relevant history (and ideally, who you spoke with should be documented!)

You must document a discrete time in minutes; a blanket statement (e.g., “at least 30 minutes was spent”) is not sufficient. It would make sense that time spent on a patient would vary from day to day, so be careful not to copy-forward your critical care attestation from one day to the other. Other things that would not be included in critical care time include:

• Updating family members
• Teaching or education to learners
• Any critical care services given by a resident physician without the presence of the teaching physician
• Time spent off the unit, including management from home via phone
• Procedures that are not bundled into the critical care CPT code

To that end, some procedures are included in a critical care billing code “bundle” and cannot be billed for separately but do count for your total critical care time. This includes the interpretation of most data, including vital signs, pulmonary artery catheter numbers, lab values, EKGs, chest x-rays and other physiological data, NG or OG placement, temporary transcutaneous pacing, ventilator management, and peripheral access procedures. Procedures that can be billed separately outside the critical care time include endotracheal intubation, pulmonary artery catheter placement, CPR, central and arterial line insertion, temporary pacemaker insertion, and chest tube insertion.

Now that you know what counts for your critical care time, how is that time billed? As mentioned earlier, anything less than 30 minutes is not considered critical care but would get a different evaluation and management (E/M) code for a subsequent hospital follow up, which is a daily bill stratified by complexity of medical decision making, not time (billing codes 99231-99233). For critical care time between 30 and 74 minutes, the billing code is 99291. Further billing is based on 30-minute increments and billed using the 99292 code subsequently as many times as necessary. For example, 35 minutes of critical care would get a 99291. Another patient receiving 80 minutes of critical care would be billed both 99291 and 99292. Here’s where things get a little tricky: starting in January 2023, Medicare requires that the full additional 30 minutes be achieved in order to bill 99292. In other words, you must have 104 (74+30) minutes of critical care services to add 99292 to a Medicare patient. For now, all other payers allow partial increments of the 30-minute interval, but this could change in the future.

Billing with Multiple Critical Care Providers

Many patients in the ICU receive care from multiple physicians or advance practice providers (APPs), to include nurse practitioners and physician assistants. How is this dealt with on the billing side? First, it is important to know that, starting in 2023, the Medicare physician fee schedule stated that the 99291 code for critical care can only be used once per day per group, even if the time is not continuous. This means that if a critical care physician and critical care APP both see a patient at different times during the day, only one of them may bill 99291, and you must accumulate your time together to meet further time-based requirements of 99292. However, providers who are not in the same group or specialty (e.g., a pulmonologist and a cardiologist managing different impaired organ systems of an ICU patient) may continue to each bill 99219 separately, as long as their services are clearly documented as non-duplicative and medically necessary. This can get a little tricky with private and hospital-owned groups and multidisciplinary critical care teams; if this applies to your hospital, we recommend discussing this with your legal department and coding specialists to ensure you are acting within the boundaries of the law.

Also starting in 2024 came the advent of “split/shared billing” for the ICU, in which physicians and APPs who work together must delineate who bills for the patient’s care. Again, this applies to services performed in part by both a physician and an APP who are in the same group or specialty, and only applies to the inpatient setting. It does include both E/M services and critical care billing. For critical care billing in the ICU, the total time is cumulative as discussed above, and whoever spends over 50% of the time will bill for the service, be it the physician or the APP. As always, documentation of time here matters. It is also important to note that:

• The physician and the APP must be in the same group and working jointly to furnish care; if they are in different groups or specialties, their time is billed separately
• The physician and the APP must see the patient at different times to count both of their time
• Billing reimbursement is different for physicians and APPs: Medicare reimburses 100% of the allowed amount for physician bills, but only 85% of the allowed amount for APPs

For E/M bills (for example, the ICU boarder who doesn’t meet critical care criteria), the rules are different. Whoever approves the care plan and assumes responsibility for the decision will bill for the service, which is almost always the physician. What if one physician and two APPs see a patient separately throughout the day? There is currently no guidance on this scenario from the government or other governing bodies, so each hospital may handle this differently. Proposed solutions include having whoever spent the most time bill or having the physician bill.

Other Unique Scenarios

It is common that intensivists are helping to care for patients in the post-operative period. As discussed above, standard care of the post-operative patient in the ICU often does not meet critical care criteria, as this is included in the global surgical package. However, this does not mean that all (or most!) of the care given to post-operative patients by the intensivist cannot be billed as critical care. For the majority of post-operative patients, true critical illness is not an expected finding after surgery. The key, again, is documentation: it must be clear that the condition is unrelated to the procedure or, if related, requires the full attention of the critical care physician and that the care is above and beyond the typical scope of the surgical procedure performed. Experts have noted that payers reserve the right here to consider discounting these services, and that to ensure these charges are accepted, the surgical intensivist must be clear in their documentation of medical necessity as a separate service. Of note, some complex cardiac surgical procedures do include expected critical care services in the global bill. This is an overall complex issue, so close communication with your coding department will be useful if you work in this environment as an intensivist.

Some other unique issues include:

• You cannot bill critical care time for a patient who has been declared brain dead, but it is likely that all care up to that point (including brain death testing) can be considered critical care.
• During the COVID-19 pandemic, billing rules were expanded to include teleICU care as a purveyor of critical care; this allowance goes through December 2024, after which the future of teleICU billing is unclear.
• Critical care can be billed on the same day as another E/M service, as long as the E/M service is a significantly separate and identifiable service. For example, a patient who is seen in the morning on the floor who deteriorates later in the day and is moved to the ICU and resuscitated would get both an E/M bill and a critical care bill. Your coders will add a billing modifier to this to show these services were unique and separate.
• If critical care time crosses midnight, all continuous care is billed for the pre-midnight date. For example, if you are giving critical care on 5/1/24 from 23:30 to 01:30 on 5/2/24, you would bill 120 minutes of critical care for the date 5/1/24 (99291 for the first 74 minutes and 99292 x 2 for non-Medicare patients, with only one 99292 for Medicare patients as you did not meet the full 134 minutes needed for that increment). If you then cared for the patient again in a separate encounter from 03:00 to 04:00 on 5/2/24, you would start again with 99291 with the billing date of 5/2/24.
• If a patient is transferring from the ICU, can you still bill critical care? Yes, but as you can imagine this might catch the attention of auditors. This would require the patient to meet the criteria for critical care at one point during the day and then be ready for transfer later in the day, which certainly can occur. Again, documentation will be vital to ensure appropriate reimbursement.
• Don’t forget to bill for discharge! This is a time-based code delineated by spending less than or greater than 30 minutes on the discharge process.

While none of us went into medicine for the coding and administrative requirements therein, this is an important part of your job. Get paid for the work you do! Good critical care billing comes down to clear documentation of medical necessity and time spent. There are some unique situations that may arise; reach out to your billing and coding department to ensure you are meeting the appropriate criteria.

Thank you to the Society of Critical Care Medicine and Deborah Grider, CPC for providing the webinar from which this information was summarized.