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

CMS and CPT count critical care time differently.

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.

CMS issued a technical correction and confirmed it in their MLN Matters article.

“We issued a technical correction clarifying that the reporting threshold time for the add-on code for critical care services is the same for split (or shared) critical care as for critical care that isn’t split (or shared). Use CPT Code 99292 to report additional, complete 30-minute time increments provided to the same patient, therefore it isn’t reported until at least 104 minutes are spent (74 + 30 = 104 minutes).”

MM 12982, Nov 17, 2022 related to CR R11708CP

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