Check Patient’s Condition, Length of Service Before Choosing 99291

Posted on 13 Sep, 2015 |comments_icon 0|By Chris Boucher

Physician must treat a ‘critical’ patient to code critical care.

If you’re thinking that your physician provided critical care service to a patient, make sure you line the encounter notes up with the definition of critical care before reporting 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).

Reason: If payers suspect you’re upcoding when the physician didn’t really perform critical care, trouble is likely coming in the form of auditors. Use these tips to keep your critical care coding copacetic with CPT® conventions.

Choose 99291 Only For ‘Critical’ Patients

In order to code 99291, you must first check to see if the patient meets the criteria for critical illness or injury. Generally, a patient is critical when one or more of his vital organ systems that are acutely impaired, and there is a high probability of an imminent, life-threatening deterioration in the patient’s condition if he doesn’t receive critical care.

Some examples of critical care scenarios include:

  • severe allergic reactions,
  • sepsis,
  • respiratory failure,
  • motor vehicle accident (MVA) with multiple injuries,
  • myocardial infarction (MI) and
  • altered mental status.

Make Sure Physician Meets Time Threshold On 99291 Claims

You’ll also need to make sure that the physician provides critical care services for a minimum of 30 minutes before choosing 99291. Otherwise, you should choose a different E/M code based on the encounter and the setting.

Remember: Critical care time does not need to be continuous; you just need to document accurate start and stop times for each period of critical care service.

Example: A patient with severe head and neck injuries after an MVA reports to the emergency department (ED). The physician provides 22 minutes of critical care to stabilize the patient upon arrival. Three hours later, the patient experiences a seizure and the physician needs to provide 20 more minutes of critical care.

Taken separately, these instances of critical care would not meet the time criteria for 99291. When combined, however, the physician has met the time criteria for 99291.

Just make sure your documentation and total critical care time are up to snuff, and this critical care claim should be paid.


Chris Boucher

Chris Boucher has nearly 10 years of experience writing various newsletters and other products for The Coding Institute. His blog will cover several areas of coding and compliance, including CPT® coding, modifiers, HIPAA compliance and ICD-10 coding.

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