Policy / Article-006
Critical Care Services Educational Guide
- Effective Date: 01/01/2026
- Reviewed/Revised Date: 03/23/2026
- Next Review Date: 03/23/2027
- Origination Date: 01/01/2026
-
Originated Department:
Correct Coding Integrity
Audience
Providers treating critical injury or illness.
- CPT 2026 Professional Edition, AMA
- AMA CPT Assistant, ED guidance
- CMS Evaluation & Management Services Guide
- Official ICD-10-CM / CPT coding rules
Clinical Providers
✓ Physicians
✓ Nurse Practitioners (NPs)
✓ PAs working in ED
Coding & Billing Professionals
✓ Medical Coders
✓ Clinical Documentation Improvement (CDI) specialists
✓ Compliance and audit personnel
Overview
Critical Care —
Direct delivery of medical care for critically ill or critically injured patients who are acutely at risk of life-threatening organ dysfunction.
➔ Focuses on high-acuity, complex care requires constant attention and decisionmaking.
➔ Usually involves high-risk interventions and intensive monitoring.
➔ Can occur in ED, ICU, or other inpatient settings.
Covering CPT Codes
99291: Critical care, first 30–74 minutes on a given date
99292: Each additional 30 minutes of critical care
Documentation Essentials
Critical care documentation should include:
✓ Patient Identification & Location – ICU, ED, or other acute care unit
✓ Reason for Critical Care – Explicit statement of life-threatening condition or organ dysfunction
✓ HPI / Pertinent History – Relevant history contributing to acute illness
✓ Assessment of Severity / Organ Systems:
- Vital signs
- Labs
- Imaging
- Hemodynamic status
- Organ support
✓ Interventions / Procedures:
- Airway management
- mechanical ventilation
- vasoactive meds
- invasive monitoring
- dialysis, etc.
✓ Time Documentation:
- Total time spent providing critical care (direct patient care)
- Note start and end times for all sessions
✓ MDM / Risk:
- High complexity, immediate life-threatening conditions
- Include rationale for interventions and management decisions
Total critical care time 95 minutes:
– Initial 30 min for airway management and resuscitation (99291),
– plus 65 min continued monitoring,titrating vasoactive medications, and coordinating care with ICU team (99292, 2 units).
1. Document the organ system involved and life-threatening conditions.
2. Include all critical interventions.
3. Record accurately all physician/qualified provider time.
4. Avoid counting routine bedside monitoring/non-critical interventions.
5. Ensure that documentation supports time-based code selection
6. Ensure accurate use of precise terminology to support 99291 vs 99292 units
Common Audit Triggers
- Lack of time documentation
- Lack of clarity regarding critical/non-critical interventions
- Lack of clarity regarding organ system failure
- Concurrent billing of non-critical E/M code for the same condition
CPT 2026 E/M Codes & Typical Time
Pro Tip
Only include physician/qualified provider time spent directly managing the critical condition.
Important
Time-based code selection is mandatory for critical care services
CPT Code
Description
Typical Time on Date of Service
MDM Level
99291
Critical care, first 3074 minutes
30-74 min
An initial critical care evaluation can include multiple problems
99292
Each additional 30 minutes
+30 min
Document total time cumulatively; only report when >74 min
Revision History
01/01/2026
Correct Coding Integrity
03/23/2026
Revised by Mountain Health CO-OP Policy Committee
Disclaimer
This document is for informational purposes only. It should not replace clinical judgment or provide medical advice. Coverage, benefits, and eligibility are determined by the member’s benefit plan. CPT codes and procedures included are for informational purposes only and do not guarantee reimbursement. © CPT Only – American Medical Association