CPT^® and CMS Rules for Critical Care | What’s the Difference?

• CMS and CPT count critical care time differently.

CMS issued a “technical correction” in the 2023 PFS Final Rule. They stated that it is their policy that add-on code 99292 can only be reported when critical care time is 104 minutes, not 74 minutes as stated in CPT^®. CMS noted they stated this in the 2022 proposed rule, but the 2022 Final Rule incorrectly used the CPT^® time chart.

For Medicare patients, the full 30 minutes of 99292 must be met in order to use the code, not the midpoint (15 minutes) of the code.

For Medicare patients:

• Use 99291 from 30 minutes until 103 minutes.
• Add on code 99292 only if the time meets 104 minutes.

[The] total time spent by the practitioners could be aggregated to meet the time
requirement to bill CPT code 99291. Under this proposal, once the cumulative required
critical care service time is met to report CPT code 99291, CPT code 99292 could not
be reported by a practitioner in the same specialty and group unless and until an
additional 30 minutes of critical care services are furnished to the same patient on the
same day (74 minutes + 30 minutes = 104 total minutes).”

“Thereafter, the physician or NPP would report CPT code 99292 for additional 30-
minute time increments provided to the same patient.” 2023 PFS Final Rule, page 675.

CodingIntel members can download the Critical Care Coding Guide for more detail.