3811 Ditmars Blvd# 1124, Astoria, NY 11105

Get the Complete Healthcare Practice Aduit Report

Edit Template

Rules for Using Critical Care CPT Codes 99291 and 99292 Effectively

Name: Cures Medical Billing Services Company
Address: 3811 Ditmars Blvd# 1124, Astoria, NY 11105, Astoria, NY, 11105, USA
Telephone: +1 (917) 994-9941

Accurate coding for critical care services (CPT 99291 and 99292) is vital for revenue integrity, but strict time documentation, pediatric nuances, and payer rules lead to costly errors. Drawing on first-hand insights from the Cures medical billing team, this guide clarifies how to code ethically, avoid audits, and maximize reimbursements.

Critical Care CPT Codes - Core Concepts

CPT 99291

Description: First 30, 74 minutes of critical care for insecure patients.
Key Criteria:
- Time must be continuous and spent on life-threatening issues (e.g., septic shock, cardiac arrest).
- Applies to all settings (inpatient, outpatient, ED).
Reimbursement: Medicare pays ~240(varies by locality); commercial payers average 240 (varies by locality); commercial payers average 275.

CPT 99292

Description: For every 30-minute increment beyond the initial 74 minutes, report 99292 in addition to 99291 (e.g., 75–104 minutes = 99291 + 99292).

Warning: Submitting code 99292 without first reporting 99291 will result in claim rejections

Pediatric & Neonatal Critical Care CPT Codes

Pediatric Critical Care (99471-99476):
- This is for patients aged 2–5 years (inpatient only).
- Example: 99471 (initial 30–74 minutes) + 99472 (each additional 30 minutes).
Neonatal Critical Care (99468-99469):
- For newborns ≤28 days old in the NICU.
- Key Rule: Time includes care coordination but excludes procedures (e.g., intubation).

Critical Care CPT Codes by Time Spent

Total Time Spent Providing Critical Care	CPT Code(s) to Report
Under 30 minutes	Use 99232, 99233, or another appropriate E/M code
30 – 74 minutes	99291 (once)
75 – 104 minutes	99291 (one unit) + 99292 (once)
105 – 134 minutes	99291 (one unit) + 99292 (twice)
135 – 164 minutes	99291 (one unit) + 99292 (three unit)
165 – 194 minutes	99291 (One unit) + 99292 (four unit)
195 minutes or more	99291 + 99292 (repeat as needed, following the structure above)

Comprehensive Healthcare Management Services

Recent Blogs

All Post
Medical
Uncategorised

Understanding the 90935 CPT Code & 97035 – Real Billing Insights

May 15, 2025

CPT Code 97014 – A Complete Guide for Physical Therapy Billing in 2025

May 13, 2025

CPT Code 97535 – Complete Guide for Physical & Occupational Therapy Billing

May 9, 2025

Contact US

Key Billing & Coding Guidelines for Critical Care CPT Codes

What Qualifies as Critical Care?

The patient’s condition must be serious and immediately threaten life or function.
Care must be justified as medically essential and align with critical care service definitions.
If a case doesn’t qualify as critical care, report it with the appropriate E/M code based on service complexity

Time Matters in Critical Care

Critical care is billed based on the total time consumed in care.
Time can be continuous or accumulated across separate visits during the same calendar day.
Providers must deliver direct, uninterrupted care at the bedside or be continuously present on the unit and ready to act.

One Provider at a Time

At any given minute, only a single provider, either a physician or a qualified non-physician practitioner, can report critical care services.
Multiple doctors can provide critical care on the same day, but not at the same time.

Providers from the Same Group

Providers in the same specialty and group practice are considered a single billing entity for critical care coding purposes.
Code 99291 is limited to a single use per group, per patient, on the same calendar day.
Physicians and non-physician practitioners within the same practice cannot combine their time for billing critical care.

Top 5 Denial Reasons (and Fixes)

Time Not Documented:
- Fix: Use EHR timestamps (e.g., “14:00–14:53 managing respiratory failure”).
Bundling with Procedures:
- Fix: Append modifier 25 if critical care is separate (e.g., 99291 + 31500 for intubation).
Incorrect Pediatric Codes:
- Fix: Use 99471 for 2-year-olds, not 99291.
POS Errors:
- Fix: Verify Point of Service (POS) (e.g., POS 23 for ED).
Unsupported Diagnosis Codes:
- Fix: Link to ICD-10 codes like R65.21 (severe sepsis) or J96.00 (respiratory failure).

Case Study - How a Children’s Hospital Reduced Denials by 50%

Challenge: A pediatric ICU faced denials for mixing 99291 with neonatal codes.
Solution:

- Trained coders to use 99468 for newborns and 99471 for toddlers.
- Added auto-reminders in EHR for time logs.
  Result: Denials dropped from 32% to 16%, saving $18,000/month.

Conclusion

Mastering critical care CPT codes requires precision in time tracking, pediatric/neonatal distinctions, and payer-specific rules. By leveraging Cures, EHR templates, and real-world strategies, your team can slash denials and safeguard revenue.

Critical care isn’t just about time it’s about proving medical necessity. Prioritize clarity, accuracy, and ongoing training to stay audit-proof.

Frequently Asked Questions (FAQs)

What is CPT code 99291 used for?

Usage CPT Code 99291 to report the first 30 to 74 minutes of critical care delivered on the same schedule day by a single provider or a team within the same specialty group.

How should I code if critical care is provided for under 30 minutes?

You cannot bill CPT 99291. Instead, use a regular E/M code such as 99232 or 99233, depending on the level of service delivered.

Is it allowed for an NPP to submit a claim for critical care services?

Yes, but only separately. NPPs must bill their own time using code 99292, and they cannot share time with a physician from the same group.

How is time counted for critical care?

All the time must be:

Face-to-face or immediately available care.
The entire reported time must be solely dedicated to one patient, without overlap.

Only time spent delivering hands-on patient care counts — documentation or admin duties are not included

Is it possible for two physicians to receive payment for critical care on the same date?

Yes, if they:

Are from different specialties.
Each manages distinct critical conditions.
Their services are not overlapping in time.

Does 99291 cover time spent calling specialists?

Yes, if it’s during active care (e.g., consulting a cardiologist).

Understanding the 90935 CPT Code & 97035 – Real Billing Insights

CPT Code 97014 – A Complete Guide for Physical Therapy Billing in 2025

CPT Code 97535 – Complete Guide for Physical & Occupational Therapy Billing

States We Serve

Discover Cures Medical Billing Services Across Different States

Florida

New York

Maryland

Colorado

New Jersey

Arizona

Texas

California

Hawaii

Georgia

North Carolina

Washington

Your Success Is Our Success

We are a team of national medical billing service experts based in Astoria, NY, committed to providing ongoing value to our customers. We leverage technology and implement best practices to provide high-quality and cost-efficient medical billing solutions from domestic locations, enabling customers to achieve their business goals. Cures Medical Billing is the best option for any medical billing needs.

At Cures Billing Services, we prioritize collaboration and recognize the uniqueness of each healthcare provider or organization
Maximize your revenue by focusing on growing your practice and let us handle all the back-end billing processes.
We can customize reports to support your practice’s unique requirements

Medical billing around Astoria, NY, and beyond is our core competency and our specialists will efficiently manage all your billing needs. Our medical billing specialists have over 12 Plus years of experience with all security technologies to ensure data integrity for our customers. Using our medical billing service, anyone can make their medical billing task less resource-consuming.