CPT® 99291; Critical care, evaluation and management of the critically ill or critically injured patient; first 30-70 minutes - JE Part B

In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.

This is to update providers of the claim review findings for CPT® 99291; Critical care, evaluation and management of the critically ill or critically injured patient; first 30-70 minutes. The results of this focused review are not a reflection on providers' competence as a health care professional or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility's compliance with the required documentation.

The Jurisdiction E, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 99291; Critical care, evaluation and management of the critically ill or critically injured patient; first 30-70 minutes. The quarterly edit effectiveness results from July 1, 2024 to September 30, 2024, are as follows:

Top Denial Reasons

• The requested records were not received
• The documentation submitted was incomplete and/or insufficient
• The documentation submitted does not support the required elements for the service billed
• The documentation submitted does not support the medical necessity of the level of service billed

Educational Resources

• How to Respond to ADR
• Documentation Guidelines for Medicare Services
• Evaluation and Management

Education

Critical care services are reported by a physician or other qualified health care provider for critically ill or injured patients. Critical illnesses or injuries are defined as those with impairment to one or more vital organ systems with an increased risk of rapid or imminent health deterioration. Critical care services require direct patient/provider involvement with highly complex decision making in order to evaluate, control, and support vital systems functions to treat one or more vital organ system failures and/or to avoid further decline of the patient's condition. Vital organ system failure includes, but is not limited to, failure of the central nervous, circulatory, or respiratory systems; kidneys; liver; shock; and other metabolic processes. Generally, critical care services necessitate the interpretation of many physiologic parameters and/or other applications of advanced technology as available in a critical care unit, pediatric intensive care unit, respiratory care unit, in an emergency facility, patient room or other hospital department; however, in emergent situations, critical care may be provided where these elements are not available. Critical care may be provided so long as the patient's condition continues to warrant the level of care according to the criteria described. Care provided to patients residing in a critical care unit but not fitting the criteria for critical care is reported using other E/M codes, as appropriate. These codes are time based codes, meaning the total time spent must be documented and includes direct patient care bedside or time spent on the patient's floor or unit (reviewing laboratory results or imaging studies and discussing the patient's care with medical staff, time spent with family members, caregivers, or other surrogate decision makers to gather information on the patient's medical history, reviewing the patient's condition or prognosis, and discussing various treatment options or limitations of treatment), as long as the clinician is immediately available and not providing services to any other patient during the same time period. Time spent outside of the patient's unit or floor, including telephone calls, caregiver discussions, or time spent in actions that do not directly contribute to the patient's care rendered in the critical unit are not reported as critical care. Report these codes for attendance of the patient during transport for patients 24 months of age or older to or from a facility. Code 99291 represents the first 30 to 74 minutes of critical care and is reported once per day. Additional time beyond the first 74 minutes is reported in 30 minute increments with 99292.

Failure to Return Records

The Internet-Only Manual (IOM) addresses timeframes for submission of records for pre-payment reviews in the Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.2.

"When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46."

Incomplete And/or Insufficient Documentation

When additional documentation has been requested to verify compliance with the CPT® code billed and the submitted documentation lacks evidence to support that, the claim will be denied as the documentation submitted was incomplete and/or insufficient. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8(C)

For additional educational resources, please visit our Education and Outreach department.