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36.3.5.2 Critical Care
Critical care is a benefit of the Texas Medicaid Program. Critical care includes the care of critically ill patients that require the constant attention of the physician. The physician must be either at bedside or immediately available to the patient. The physician must devote his full attention to the patient and therefore, cannot render E/M services to any other patient during the same period of time. Critical care is usually given in a critical care area, such as the coronary care unit, intensive care unit, respiratory care unit, neonatal intensive care unit, or the emergency department care facility.
Procedure codes 1-99291 (the first 30-74 minutes) and 1-99292 (each additional 30 minutes beyond the first 74 minutes) should be used to submit claims for daily critical care services. Procedure code 1-99291 should be used only once for the first 30-74 minutes of critical care even if the time spent by the physician is not continuous on that day. Procedure code 1-99292 is allowed up to 6 units or 3 hours each day. If the number of units is not stated on the claim, a quantity of 1 is allowed.
Procedure codes 1-99293 (initial) and 1-99294 (subsequent) should be used to report inpatient pediatric critical care each day for the E/M of a critically ill infant or young child between 29 days and 24 months old.
The following procedure codes are denied as part of another service if submitted with the same date of service by the same provider as procedure codes 1-99291 and 1-99292. This is not an all-inclusive list:
The following procedure codes are denied as part of another service if submitted with the same date of service by the same provider as procedure codes 1-99293 and 1-99294. This is not an all-inclusive list:
Services for a patient who is not critically ill and unstable but who happens to be in a critical care unit must be reported using subsequent hospital visit codes or hospital consultation codes.
Critical care and pediatric critical care (procedure codes 1-99291, 1-99292, 1-99293, and 1-99294) provided on the same day as a major surgery, by the same provider who performed the surgical procedure must be submitted with documentation that the critical care was unrelated to the specific anatomic injury or general surgical procedure.
Critical care (procedure codes 1-99291 and 1-99292) may be submitted only by the provider rendering the critical care service at the time of the crisis. Critical care involves high complexity decision-making to access, manipulate, and support vital system functions. While providers from various specialties (for example: cardiology, neurology) may be consulted to render an opinion and/or assist in the management of a particular portion of the care, only the provider managing the care of the critically ill patient during a life threatening crisis may submit the critical care procedure codes.
If initial critical care (procedure code 1-99291) is provided by different physicians who meet the initial 30-minute time requirement, and the care is provided at separate distinct times, the initial provider's claim is considered for reimbursement. The second provider's claim is denied but may be considered on appeal. The time spent by each physician cannot overlap - two physicians cannot bill critical care for care delivered at the same time to the same patient. Supporting medical record documentation must be provided by the second physician and must include the time in which the critical care was rendered. In addition, a statement must be submitted indicating the physician was the only provider managing the care of the critically ill patient during the life threatening crisis.
If the provider's time exceeds the 74 minute time threshold for procedure code 1-99291, procedure code 1-99292 may be submitted in addition to procedure code 1-99291 for each additional 30 minutes. Procedure code 1-99292 may not be submitted as a stand alone procedure code.
Inpatient pediatric critical (procedure codes 1-99293 and 1-99294) is a per-day charge. Only one physician can submit the procedure codes for pediatric critical care per day. If an inpatient E/M service is submitted with the same date of service as pediatric critical care by the same provider, the inpatient E/M is denied.
If the critical care services are provided to a neonatal, pediatric, or adult client in an outpatient setting such as an emergency room, and the services do not result in admission, providers should use procedure codes 1-99291 and 1-99292.
If a hospital discharge (procedure codes 1-99238 and 1-99239) is submitted with the same date of service as pediatric critical care (procedure codes 1-99293 and 1-99294), the hospital discharge is denied, and the critical care is considered for reimbursement.
If critical care (procedure codes 1-99291 and 1-99292) is provided to a patient at a distinctly separate time from another outpatient E/M service by the same provider, both services may be considered for reimbursement with supporting medical record documentation.
Prolonged physician service (procedure codes 1-99354, 1-99355, 1-99356, 1-99357) are denied when submitted with the same date of service as critical care (procedure codes 1-99291 and 1-99292) by the same provider.
Claims for seemingly improbable amounts of critical care on the same date may be subject to review to determine if the physician has filed a false claim.
Critical care procedure codes 1-99291 and 1-99292 are denied when submitted with the same date of service as neonatal intensive care codes 1-99295, 1-99296, 1-99298, 1-99299, or 1-99300.
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