Critical Care Billing FAQs

The basics and the nuances

Author

Robert Oubre, MD
November 08, 2025 • Estimated Reading Time: 16 minutes

Close revenue cycle gaps at the point of conversation by transforming every clinician-patient encounter into audit-ready, billable documentation in real time—with zero back-and-forth. Learn more.

Questions about critical care billing are some of the most common I get.

I’ve mostly avoided writing about it until a recent MLN from CMS caught my attention. It highlighted some nuances I hadn’t fully appreciated. Then, after my Linkedin post about it took off, I figured it was time for a newsletter.

So, let’s dig in.

The Overview

Critical care billing is fairly straightforward: it’s time-based.

99291 covers 30 to 74 minutes of critical care time.

If you don’t meet the minimum 30-minute threshold, you’ll need to bill the appropriate E&M charge (initial or subsequent hospital visit, as appropriate).

99292 is an add-on code used when you exceed the 74 minutes covered by 99291. This is where things start to get tricky… we’ll come back to that.

But let’s start with the foundation.

The Basics

First, as always, a prerequisite to any charge is medical necessity. Sure, you may have spent 35 minutes taking care of a patient who is physically located in the ICU, but is a critical care charge medically necessary? And is your involvement in the case medically necessary in the first place (this must be stated, unfortunately). Medical necessity can be a bit subjective, but it’s actually laid out pretty clearly by CMS:

“Critical care is the direct delivery by a physician(s) or other qualified healthcare professional (QHP) of medical care for a critically ill/injured patient in which there is acute impairment of one or more vital organ systems, such that there is a probability of imminent or life-threatening deterioration of the patient’s condition. It involves high complexity decision-making to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition.” (emphasis added by me)

Author: CMS aka The U.S. Government.

The above quotation and the rest below are from this CMS document.

To that end, many develop dot phrases / macros that insert this language to ensure this medical necessity is documented as well as some of the requirements detailed below. But as I’ve said before, don’t just document something because it’s “required for billing.” Document it because it’s true and accurate.

So what about beyond that 99291 code?

Well, this is where CMS and the AMA/CPT differ.

Say what now?

CMS & AMA/CPT: A quick refresher

The CPT code set (the codes that capture the specific services/procedures performed by physicians and “qualified healthcare providers” (QHPs) or “non-physician practitioners” (NPPs) as the AMA/CMS calls them) is developed by the American Medical Association. It is then up to CMS to decide if they agree/accept the guidelines laid out by the AMA regarding those CPT codes. Sometimes they do not and CMS will publish their own criteria.

It’s then up to payers (I don’t love that term) to decide which guidelines they’ll follow and for what codes they’ll pay. That’s why there are some CPT codes that exist… but no insurance company pays anything for them. So, it’s not worthwhile to use them.

CMS is obviously a “big payer” (and sets guidelines / regulations themselves, of course) so many other payers follow their lead. This is all complicated, so that’s why coders are crucial to making sure your submitted codes are accurate because no one expects you to change your coding (or documentation) based on payer. Coders typically use software that alerts them to these nuances.

AMA/CPT vs CMS 99292 time differences

CMS will pay out a 99292 “add-on code” when the full additional 30 minutes beyond the initial 74 minutes has been met. So: 99291 for the first 30 - 74 minutes, 99292 for >104 minutes (74 + 30).

However, the AMA/CPT says 99292 can be coded for time “up to” 30 minutes beyond the first 74 minutes using the “midpoint” threshold… but don’t get lost in the lingo. For the AMA/CPT, you can code 99292 (in addition to 99291) with >75 minutes (up to 104 minutes) of critical care time. Then, the AMA/CPT allows an additional 99292 with >105 minutes (up to 134 minutes) of critical care time.

This differs from CMS who says 99292 should only be reported when >104 minutes (74 + 30) have been met, then >134 minutes (103 +30) for the second 99292.

(Big thank you to Betsy Nicoletti for helping me understand these differences. Check out this coding intel post for a nice little chart on the above. She has a membership if you’re interested).

Anyhow… document what you did. Leave the rest to the coders.

No double dipping.

For anyone familiar with E&M / professional billing, this should be a familiar concept. You cannot include something in your E&M / critical care time that you are also billing for separately. Example: A cardiologist who charged for an EKG read can’t then use that EKG read as part of their MDM points for their E&M charge. No double dipping. This is what CMS says is included:

“Bundled services that are included by CPT in critical care services and therefore not separately payable include interpretation of cardiac output measurements, chest X rays, pulse oximetry, blood gases and collection and interpretation of physiologic data (for example, ECGs, blood pressures, hematologic data), gastric intubation, temporary transcutaneous pacing, ventilator management, and vascular access procedures. As a result, these codes are not separately billable by a practitioner during the time-period when the practitioner is providing critical care for a given patient. Time spent performing separately reportable procedures or services should be reported separately and should not be included in the time reported as critical care time.”

Procedures such as resuscitation, endotracheal intubation, and central line insertion can be billed separately but make sure your note clearly states that time spent doing these procedures was not included in your critical care time.

Other details about 99291 and 99292:

Does the time have to be continuous?

No.

“CPT code 99291 will be used only once per date even if the time spent by the practitioner is not continuous on that date… Thereafter, the physician or NPP will report CPT code 99292 for additional 30- minute time increments provided to the same patient. CPT codes 99291 and 99292 will be used to report the total duration of time spent by the physician or NPP providing critical care services to a critically ill or critically injured patient, even if the time spent by the practitioner on that date is not continuous. Non-continuous time for medically necessary critical care services may be aggregated.”

What about when the critical care services crosses midnight?

If it’s a continuous service, report the total time. But, if the care is disrupted (such as having to care for another patient), then that starts a new initial service on that second calendar date past midnight:

“Regarding critical care services crossing midnight, CPT guidance defines how a service is to be billed when the service extends across calendar dates. For continuous services that extend beyond midnight, the physician or NPP will report the total units of time provided continuously. Any disruption in the service, however, creates a new initial service. We are adopting this rule for critical care being furnished by a single physician or NPP when the critical care crosses midnight.”

What about two providers in the same group providing critical care for the same patient on the same date?

This was a new one for me that I learned after the recent MLN (and is new as of 2022). Essentially, add up the time as an aggregate, following the same time-based guidelines as above. See the additional caveats below:

“When one practitioner begins furnishing the initial critical care service, but does not meet the time required to report CPT code 99291, another practitioner in the same specialty and group can continue to deliver critical care to the same patient on the same date. The total time spent by the practitioners is aggregated to meet the time requirement to bill CPT code 99291. Once the cumulative required critical care service time is met to report CPT code 99291, CPT code 99292 can only be reported by a practitioner in the same specialty and group when an additional 30 minutes of critical care services have been furnished to the same patient on the same date (74 minutes + 30 minutes = 104 total minutes).”

What about split/shared services with a physician and NPP?

Whoever provided >50% of the time, they should drop the code. But, again, no double dipping. If you and the NPP are seeing the patient/providing services at the same time, that time can only be counted once. Each provider should document what they did and the time they spent providing critical care. Oh and don’t forget the -FS modifier (again, coders can/should do this for you).

“Also, the substantive portion for critical care services is defined as more than half of the total time spent by the physician and NPP beginning January 1, 2022. In the context of critical care, split (or shared) visits occur when the total critical care service time furnished by a physician and NPP in the same group on a given calendar date to a patient is summed, and the practitioner who furnishes the substantive portion of the cumulative critical care time reports the critical care service(s).

Consistent with all split (or shared) visits, when two or more practitioners spend time jointly meeting with or discussing the patient as part of a critical care service, the time can be counted only once for purposes of reporting the split (or shared) critical care visit.

Modifier -FS (split or shared E/M visit) must be appended to the critical care CPT code(s) on the claim.”

By the way, I run an online community for CDI specialists and coders. This week, one of or members made a post just to say how much she’s loving the community 👇️ . We have monthly webinars (15 recorded - immediately available to members, each with a PDF summary of that topic), 400+ forum discussions, and you’ll get exclusive access to my one-page CDI tip card. Come check us out with a 7 day free trial!

Do you have to itemize your time or provide a start/stop time?

No. But do provide a total time, do not provide a range of time and do not use “greater than” language. See below.

“Critical care is a time-based service, and therefore, practitioners must document in the medical record the total time (not necessarily start and stop times) that critical care services are furnished by each reporting practitioner. Documentation needs to indicate that the services furnished to the patient, including any concurrent care by the practitioners, are medically reasonable and necessary for the diagnosis and/or treatment of illness and/or injury or to improve the functioning of a malformed body member. “

Can you drop an E&M code and a critical care code on the same day on the same patient?

Yes, but only if the E&M was separate from the critical care, and the patient didn’t need critical care at the time of the E&M service. Make sure documentation (including two separate notes) shows why each was medically necessary. You’ll need the 25 modifier to indicate these are two seperate encounters.

“When critical care services are reported the same date as another E/M visit, the medical record documentation must support: 1) that the other E/M visit was provided prior to the critical care services at a time when the patient did not require critical care, 2) that the services were medically necessary, and 3) that the services were separate and distinct, with no duplicative elements from the critical care services provided later on that date. When critical care services are furnished in conjunction with a global procedure, the medical record documentation must support that the critical care was unrelated to the procedure, as discussed above.”

Can you include time spent doing activities off the unit or off the floor of the patient?

Although CMS and the AMA/CPT differ in their language here, they essentially say the same thing and the answer is no. You must be on the unit with the patient. The AMA/CPT says it outright that the patient must be “immediately available” to the practitioner. CMS says the patient must have your “full attention.”

“Critical care requires the full attention of the physician or NPP and therefore, for any given time period spent providing critical care services, the practitioner cannot provide services to any other patient during the same period of time.”

Lastly, can multiple providers from different specialties submit critical care codes?

Yes!

“In the context of critical care services, a critically ill patient may have more than one medical condition requiring diverse, specialized medical services and requiring more than one practitioner, each having a different specialty, playing an active role in the patient’s treatment. Medicare policy allows critical care visits furnished as concurrent care (or concurrently) to the same patient on the same date by more than one practitioner in more than one specialty (for example, an internist and a surgeon, allergist and a cardiologist, neurosurgeon and NPP), regardless of group affiliation, if the service meets the definition of critical care and is not duplicative of other services.”

Below is a banger of a chart CMS released in that MLN summarizing much of the above.

Wrapping it up

Critical care coding is one of those topics that looks simple at first glance but quickly turns into a maze of time thresholds, documentation nuances, and payer-specific quirks. The key is to stay grounded in what matters most: medical necessity, accuracy, and clear documentation.

If you document what you actually did, capture the total time, and make sure your note reflects the patient’s true level of illness (including the life-threatening aspect of their impairment of one or more organ systems), you’ll be fine. Use EMR documentation technologies to help you out - but make sure they’re true and accurate.

Coders can handle the rest.

If you found this breakdown helpful, share it with your colleagues! Don’t forget to subscribe to this newsletter if you’re not already, and follow me on Linkedin!

That’s all for now. Cheers,

Robert

Thank you to Laura Samson, RN BSN CCDS and Kristi Knight, RN CPC CPPM CCDS-O for reviewing this newsletter!

Check out what other subscribers are enjoying:

  1. Our CDI and Coding Village online community. Join with a 7-day free trial! It’s impossible to know it all, it takes a village! What you’ll get:

  • >15 hours of recorded webinars hosted by me and other experts!

  • My exclusive CDI Tip card!

  • Access to our forums (with >400 topics and growing) where you can share ideas & solutions to new problems with peers in real-time discussions!

  • Cover your cost (and then some) with our affiliate and village advisor programs!

  • Master the new 2021 / 2023 E&M Guidelines

  • Write shorter notes and get home faster with 100% confidence you’re billing appropriately.

  • Get 3.5 hours of CME credit! (Use your CME funds!)

  • Use notes to protect yourself from lawsuits

  1. The Resident Guide to Clinical Documentation video course. The course that interns and residents:

  • Impress your attendings and improve your evaluations.

  • Prepare for real-world productivity pressures.

  • Gain the confidence to write shorter yet more effective notes.

  • Use notes as a checklist to prevent mistakes and provide more complete care.

If you were forwarded this newsletter and would like to subscribe:

Reply

or to participate.