Critical Care Codes (CPT 99291, 99292)

🫀 Critical Care Coding Guide (CPT 99291, 99292)

Last Updated: September 2026
Regulatory Baseline: 2026 CMS Physician Fee Schedule (PFS) & AMA CPT Guidelines

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📌 Executive Summary & Core Definitions

Critical care is the direct medical evaluation and management of a critically ill or critically injured patient. Unlike routine Evaluation and Management (E/M) services, critical care is exclusively time-based and is governed by strict clinical criteria and rigorous procedure time carve-out rules.

Dual Clinical Criteria for Critical Care

To report critical care services (99291, 99292), the documentation must clearly satisfy two distinct requirements:

1. Critical Illness / Injury (Patient Acuity): An acute impairment of one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition (e.g., circulatory failure, acute respiratory failure, septic shock, acute renal failure requiring emergent dialysis, severe metabolic encephalopathy, active life-threatening GI bleeding).
2. Critical Care Service (Physician Intervention): High-complexity Medical Decision Making (MDM) to assess, manipulate, and support vital organ system function(s) to treat vital organ system failure and/or to prevent further life-threatening deterioration. Constant active physician/QHP management and direct attention are required.

Location Independence

Critical care is service-based, not site-of-service based. It is commonly delivered in intensive care units (ICUs, CCUs, PICUs, SICUs), but it may be furnished anywhere in the hospital—including the Emergency Department (ED, POS 23), Step-down/Progressive care units, Inpatient hospital floors (POS 21), Observation units (POS 22), or the Post-Anesthesia Care Unit (PACU).

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⏱️ Primary Codes & 2026 RVU Data

CPT Code	Description	Cumulative Time on DOS	2026 wRVU	Global Period	Assistant Fee
99291	Critical care, evaluation and management of the critically ill or critically injured patient; first 30–74 minutes	30 – 74 min	~4.50	XXX	No
99292	Critical care, evaluation and management; each additional 30 minutes (List separately in addition to code for primary service)	Each addl 30 min (beyond 74 min)	~2.25	ZZZ	No

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📊 Critical Care Time Threshold Calculation Table

Critical care time is calculated as the cumulative total time spent by a practitioner (or practitioners within the same specialty and group) on a single calendar date.

Total Cumulative Time (Single Calendar Day)
├── < 30 Minutes ─────────► DO NOT bill critical care! Bill appropriate E/M code
├── 30 – 74 Minutes ──────► Bill 99291 × 1
├── 75 – 104 Minutes ─────► Bill 99291 × 1 + 99292 × 1
├── 105 – 134 Minutes ────► Bill 99291 × 1 + 99292 × 2
├── 135 – 164 Minutes ────► Bill 99291 × 1 + 99292 × 3
├── 165 – 194 Minutes ────► Bill 99291 × 1 + 99292 × 4
└── > 194 Minutes ────────► Add 1 unit of 99292 for each additional 30-min block (≥15 min midpoint)

Total Cumulative Time Spent	Primary Code	Add-on Code Units	Claim Reporting
< 30 minutes	—	—	Bill standard E/M (99222–99223, 99232–99233, or 99284–99285)
30 – 74 minutes	99291	None	99291
75 – 104 minutes	99291	99292 × 1	99291, 99292
105 – 134 minutes	99291	99292 × 2	99291, 99292 × 2
135 – 164 minutes	99291	99292 × 3	99291, 99292 × 3
165 – 194 minutes	99291	99292 × 4	99291, 99292 × 4
195 – 224 minutes	99291	99292 × 5	99291, 99292 × 5

The 15-Minute Midpoint Rule for 99292

To bill the first unit of 99292, the provider must spend at least 75 minutes (which is 1 minute past the 74-minute cap of 99291, meeting the 15-minute midpoint of the first 30-minute increment: 60 + 15 = 75 min). Each subsequent unit of 99292 requires passing the 15-minute midpoint of that subsequent 30-minute block (e.g., 75 + 30 = 105 min).

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⏱️ Qualifying vs. Non-Qualifying Activities

Critical care time includes time spent directly delivering care to the patient at the bedside, as well as time spent on the unit/floor directly dedicated to that specific patient’s management.

✅ Billable / Countable Time

• Direct bedside examination and evaluation of the unstable patient.
• Reviewing extensive diagnostic data: Chart review, laboratory panels, blood gas analysis, electrocardiograms, imaging studies, hemodynamic monitors, and telemetry trends.
• Active unit-based discussions: Conferring with bedside intensive care nurses, respiratory therapists, clinical pharmacists, and medical/surgical consultants regarding specific treatment modifications and titration orders.
• Medical record documentation: Writing critical care orders, documenting progress notes, charting assessments, and outlining immediate intervention plans while on the unit.
• Family discussions (STRICT CRITERIA): Time spent conferring with family members or designated surrogate healthcare decision-makers ONLY IF:
  1. The patient is unable or incompetent to participate in decision-making (e.g., intubated, comatose, severely encephalopathic, sedated).
  2. The discussion is strictly necessary for obtaining medical history or determining treatment decisions/goals of care (e.g., surrogate consent, code status, advanced directives, withdrawal of life support).
  3. The discussion takes place on the unit or at the bedside.

❌ Non-Billable / Excluded Time

• Separately billable procedural services: Time spent performing procedures (e.g., intubation, central line placement) must be carved out and cannot be counted toward critical care time.
• Routine family updates: Providing emotional reassurance, bereavement counseling, general condition summaries, or answering questions when no management decisions are being made.
• Teaching and educational time: Time spent teaching residents, fellows, or medical students (unless the teaching physician is personally performing/involved in direct patient management).
• Waiting / Standby time: Time spent waiting for laboratory results, waiting for an operating room to open, or resting between clinical episodes.
• Administrative tasks: General unit management, billing paperwork, or attending multi-patient interdisciplinary administrative meetings.
• Overlapping / Simultaneous patient care: Clinicians cannot count time spent simultaneously caring for another patient.

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📦 Bundled Services vs. Separately Billable Procedures

CPT guidelines explicitly bundle specific routine intensive care diagnostic and therapeutic services into 99291 and 99292. These services cannot be reported separately on the same date by the same provider/group. However, the time spent performing them is counted toward total critical care time.

1. Services Bundled into Critical Care (Do NOT Bill Separately)

Organ System / Category	Bundled CPT Codes	Clinical Description
Vascular Access	36000, 36410, 36415, 36591, 36600	Routine peripheral IV insertion, routine venipunctures, capillary blood collection, collection of blood from central line, routine arterial puncture.
Pulmonary / Respiratory	71045, 71046, 94002–94004, 94660, 94662, 94760–94762	Routine chest X-rays (single/2 views), ventilator management (initial/subsequent/home), CPAP/BiPAP initiation and management, continuous pulse oximetry.
Gastrointestinal	43752, 43753	Nasogastric (NG) / orogastric tube placement, gastric intubation and aspiration/lavage.
Cardiac / Hemodynamic	92953, 93561, 93562	Temporary transcutaneous pacing, indicator dilution cardiac output measurements (subsequent/initial).
Diagnostic Interpretation	82800–82810, 99090	Interpretation of arterial blood gases (ABGs), computer-stored data analysis.

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2. Separately Billable Procedures (The Procedure Time Carve-Out Rule)

Invasive bedside surgical and procedural interventions are not bundled into critical care. They may be billed separately using their distinct CPT codes.

Mandatory Procedure Time Carve-Out

When a physician performs a separately billable procedure while managing a critically ill patient, the time dedicated to performing that procedure CANNOT be counted toward critical care time.

The provider must explicitly document:

1. Total critical care time.
2. Total procedure time.
3. Confirmation that procedure time was subtracted/carved out from the reported critical care time.

Bedside Procedure	CPT Code	Modifier	Carve-Out Requirement
Endotracheal Intubation	31500	None / -59 if edit	Deduct intubation time (e.g., 15 min) from CC time
Central Venous Catheter Insertion (Non-tunneled)	36556 (age 5+) / 36555 (<5)	None	Deduct line placement time (e.g., 20–30 min)
Arterial Line Placement (Percutaneous)	36620	None	Deduct A-line insertion time (e.g., 15 min)
Tube Thoracostomy (Chest Tube)	32551	None	Deduct chest tube insertion time (e.g., 25 min)
Cardiopulmonary Resuscitation (CPR)	92950	None	Deduct active CPR resuscitation time
Temporary Transvenous Pacemaker	33210	None	Deduct catheter insertion and pacing setup time
Ultrasound Guidance for Vascular Access	76937	None	Deduct imaging and vessel verification time
Diagnostic / Therapeutic Lumbar Puncture	62270	None	Deduct LP positioning, puncture, and fluid time
Thoracentesis / Paracentesis	32554–32555 / 49082–49083	None	Deduct aspiration and drainage time

📝 Carve-Out Example

• Scenario: An intensivist spends 85 minutes total in the ICU managing a patient in refractory septic shock with respiratory collapse.
• Procedures Performed:
  • Intubation (31500) = 15 minutes.
  • Central Line Placement (36556) = 20 minutes.
• Calculation: $\text{Net Critical Care Time}=85\text{ min}-(15\text{ min}+20\text{ min})=50\text{ minutes}$
• Coding:
  • 99291 (covers the 50 minutes of net critical care).
  • 31500 (Intubation).
  • 36556 (Central venous catheter).
  • (Do NOT bill 99292, because net CC time is 50 min, which is < 75 min).

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👥 Split/Shared Critical Care Visits (CMS 2024–2026 Rules)

Under Medicare guidelines (CMS IOM Pub. 100-04, Ch. 12, §30.6.18), split (or shared) critical care visits occur when a physician and a Non-Physician Practitioner (NPP / NP / PA) from the same group practice jointly furnish critical care to a patient on the same calendar date in a recognized facility setting (POS 21 Inpatient, POS 22 Outpatient/Observation, POS 23 ED).

Split/Shared Critical Care Time Calculation
├── Physician Time:  35 mins
├── NP/PA Time:      45 mins
├── Combined Total:  80 mins (Supports 99291 + 99292)
└── Billing Provider Determination:
    ├── Physician (35/80 = 43.8%) ──► < 50% (Cannot bill under MD)
    └── NP/PA (45/80 = 56.2%) ──────► > 50% ──► NP/PA Bills 99291-FS + 99292-FS (Paid at 85%)

Key Regulatory Rules for Split/Shared Critical Care

1. Time-Only Substantive Portion: Unlike standard E/M visits where the substantive portion can be determined by MDM or time, critical care substantive portion is strictly determined by total cumulative time.
2. More Than Half (> 50% Rule): The practitioner who personally performs more than 50% of the total combined critical care time is the billing practitioner.
3. Modifier -FS: Must be appended to both 99291 and 99292 to identify the claim as a split/shared visit.
4. No Overlapping Time: Time spent together at the bedside by both the physician and the NPP can only be counted once toward total time.
5. Reimbursement:
   • If the Physician performs > 50% of the time $\to$ Billed under MD NPI with -FS (Reimbursed at 100% of PFS).
   • If the NPP performs > 50% of the time $\to$ Billed under NPP NPI with -FS (Reimbursed at 85% of PFS).

Split/Shared Documentation Requirement

Both practitioners must document their individual involvement, individual non-overlapping times spent, and specific clinical activities. The billing practitioner must sign and date the medical record.

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🎓 Teaching Physician Guidelines (Modifier -GC)

When a teaching physician supervises a resident or fellow providing critical care, specific CMS guidelines apply:

1. 100% Physical Presence Rule: The teaching physician must be personally present for the entire duration of the time billed as critical care (e.g., if 60 minutes of critical care is billed, the teaching physician must have been present for the full 60 minutes).
2. Exclusion of Resident-Alone Time: Time spent by a resident alone reviewing records, examining the patient, or documenting cannot be counted toward the teaching physician’s critical care time.
3. Teaching Attestation Documentation: The teaching physician must personally document:
   • Total time the teaching physician personally spent providing critical care.
   • Confirmation of physical presence during that time.
   • Clinical assessment of critical illness and organ failure.
   • Specific management interventions and high-complexity decision-making provided.
4. No Primary Care Exception: The Primary Care Exception (PCE / -GE) never applies to critical care. Modifier -GC is appended to indicate teaching physician involvement.

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🔄 Same-Day Services, Multiple Specialties, & Global Surgery

1. Same-Day Routine E/M + Critical Care (Modifier -25)

• Scenario: A hospitalist performs a morning subsequent hospital visit (99233) on a stable inpatient. Later that afternoon, the patient experiences sudden acute aspiration, septic shock, and respiratory failure, requiring 60 minutes of emergency critical care (99291).
• Billing Rule: Both services are billable.
  • Bill the subsequent hospital care code with Modifier -25 (e.g., 99233 -25).
  • Bill the critical care code (99291).
  • Requirement: Documentation must prove that the earlier E/M visit was completed prior to the onset of critical deterioration and constituted a distinct, separate clinical encounter.

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2. Concurrent Critical Care by Multiple Specialties

• Same Specialty / Same Group: Physicians of the same specialty in the same group cannot bill separate critical care codes on the same date. Their time must be aggregated into a single claim (e.g., Partner A 30 min + Partner B 30 min = 60 min $\to$ Bill 99291 × 1).
• Different Specialties: Multiple physicians of different specialties can each bill critical care on the same date provided that:
  1. Each physician is actively managing a distinct, non-overlapping organ system failure within their scope of expertise.
  2. The care is fully non-duplicative and medically necessary.
  • Example: A Critical Care Intensivist manages multi-organ septic shock and pressors (99291), a Nephrologist manages acute oliguric renal failure requiring initiation of CRRT (99291), and a Trauma Surgeon manages active intra-abdominal hemorrhage and coagulopathy (99291).

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3. Critical Care During Global Surgical Periods (Modifier -FT vs. -24)

Modifier	Payer Scope	Billing Circumstance
-FT	Medicare Part B	Reported on critical care codes (99291, 99292) when critical care is provided by the operating surgeon (or same group/specialty) during a global surgical period (10-day or 90-day), or on the same day as surgery, unrelated to the surgical procedure itself (e.g., patient undergoes elective hip replacement and postoperatively develops acute myocardial infarction with cardiogenic shock).
-24	Commercial / Non-Medicare	Used on E/M codes to indicate unrelated E/M service during a postoperative global period. (Note: For Medicare critical care claims, CMS mandates modifier -FT instead of -24).
-25	All Payers	Used when pre-operative critical care is provided on the same day as an emergency surgical procedure to stabilize the patient prior to entering the OR.

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📋 Auditor-Proof Critical Care Documentation Checklist

When defending critical care claims against Medicare Advantage, MAC, and commercial audit scrutiny, ensure the chart includes these seven vital elements:

• 1. Vital Organ System Failure Identified: Explicit documentation of acute life-threatening organ system dysfunction (e.g., acute respiratory distress syndrome, hemodynamic instability requiring continuous norepinephrine infusion, acute renal shutdown, severe acidosis with pH < 7.15).
• 2. High-Complexity Interventions: Documentation of active pharmacologic titration, ventilator adjustments, fluid resuscitation, and continuous hemodynamic monitoring.
• 3. Exact Cumulative Time Documented: Total critical care time stated explicitly in minutes (e.g., “Total critical care time spent: 65 minutes”). Avoid ambiguous statements like “Spent over an hour on the unit.”
• 4. Explicit Carve-Out Statement: “Total time excludes time spent performing separately billable procedures (intubation and central line placement).”
• 5. Family Meeting Criteria Met (if time included): Documentation clearly specifies patient lacked capacity, discussion focused strictly on surrogate treatment decisions / code status, and family members were identified.
• 6. Split/Shared Specifics (if applicable): Separate entries by MD and NP detailing individual non-overlapping times and clinical activities, with modifier -FS appended by the majority-time clinician.
• 7. Teaching Physician Physical Presence (if applicable): Attestation confirming 100% direct physical presence for the full duration of billed critical care time with modifier -GC.

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🔗 Related Vault Resources

• 00 Inpatient ProFee Coding MOC — Inpatient ProFee Master Map of Content
• 01 Inpatient ProFee Overview — Foundational ProFee Guidelines
• Inpatient E&M Codes — Hospital Inpatient & Observation E/M Services
• FS — Split-Shared Visits — Comprehensive Split/Shared Billing Rules & Modifier -FS
• GC — Teaching Physician Rules — Teaching Physician Regulations & Supervision Levels
• Modifier -25 vs -57 — Modifier 25 & 57 Decision Hierarchy
• Inpatient Modifiers — Master Modifier Reference for Inpatient Professional Claims
• Prolonged Services — Non-Critical Care Prolonged Services (99418 vs. G0316)
• CMS Medicare Guidelines for Inpatient — CMS Payment Policies and Regulations
• CPT Assistant References for Inpatient — CPT Assistant Precedents & Audit Defense
• Primary Codes: 99291, 99292
• Bedside Procedures: 31500 (Intubation), 36556 (Central Line), 36620 (A-Line), 32551 (Chest Tube), 92950 (CPR)
• Key Modifiers: -25, -FT, -FS, -GC, -59, -AI