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24.3.12.4 Critical Care Services
Critical care is a benefit of the CSHCN Services Program. Authorization is not required for these services.
Critical care is the care of a critically ill client who requires constant physician attention. Critical care involves high complexity decision making to access, manipulate, and support vital system functions. If the physician is not at bedside they must be immediately available to the client. The physician must devote their full attention to the client and therefore, cannot render E/M services to any other client during the same period of time. Critical care is usually given in a critical care area such as, a coronary care unit, a respiratory care unit, an intensive care unit, a pediatric intensive care unit, a neonatal intensive care unit, or an emergency department care facility.
Noncritical intensive care is a benefit for those infants that are low birth weight or very low birth weight who no longer meet the definition of critically ill but continue to require intensive observation and frequent services and interventions only available in the intensive care setting.
Newborn resuscitation is a benefit for high risk newborns who require resuscitation.
General Limitations
Critical care provided to a neonate or a child in an outpatient setting (e.g., emergency room) which does not result in admission, should be billed using procedure codes 1-99291 and 1-99292.
If outpatient critical care (procedure codes 1-99291 and 1-99292) is provided to a patient at a distinctly separate time than another outpatient E/M service, by the same provider, both services may be considered for reimbursement with supporting medical record documentation.
Neonatal critical care (procedure codes 1-99295 and 1-99296), pediatric critical care (procedure codes 1-99293 and 1-99294), and critical care (procedure code 1-99291) are limited to one per day for the same provider. Subsequent critical care (procedure code 1-99292) is each additional 30 minutes beyond the first 74 minutes of critical care and is limited to a quantity of 6 units (3 hours) per day.
Neonatal and pediatric critical care, and low birth weight services are inpatient, per day charges and only billable once per day by the same provider. No other inpatient E/M services are considered for reimbursement on the same day when billed by the same provider.
If critical care (procedure code 1-99291) is provided by different physicians that meet the initial 30 minute time requirement and the care is provided at separate distinct times, the initial provider's claim will be paid. 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.)
Supporting medical record documentation must be provided by the second physician that includes 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 billed in addition to procedure code 1-99291 for each additional 30 minutes. Procedure code 1-99292 may not be billed as a stand alone code.
Critical care provided on the same day as a major a surgery must billed with documentation that the critical care was unrelated to the specific anatomic injury or general surgical procedure.
Services for a client who is not critically ill and unstable but who happens to be in a critical care unit must be billed using subsequent hospital visit codes or hospital consultation codes.
Prolonged physician services (procedure codes 1-99354, 1-99355, 1-99356, and 1-99357) are denied when billed on the same date of service as any critical care, neonatal intensive care, or intensive low birth weight (low birth weight or very low birth weight) services (procedure codes 1-99291, 1-99292, 1-99293, 1-99294, 1-99295, 1-99296, 1-99298, 1-99299, and 1-99300) by the same provider.
Critical care is only billable by the provider rendering the critical care service while the client is critically ill. While providers from various specialties (e.g., cardiology, neurology) may be consulted to render an opinion 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 bill the critical care.
Services for a client who is not critically ill and unstable, but who happens to be in a critical care unit, must be billed using subsequent hospital visit codes or hospital consultation codes.
Physicians may be reimbursed at the lower of the billed amount or the amount allowed by the Texas Medicaid Program.
APNs and CRNAs may be reimbursed at the lower of the billed amount or 92 percent of the amount allowed by the Texas Medicaid Program for physicians for the same service. To provide CSHCN Services Program services, each NP or CNS must be licensed as a registered nurse and recognized as an APN by the Texas BON.
Critical care services are subject to retrospective review.
Critical Care
Procedure codes 1-99291 and 1-99292 are used to identify critical care services provided to clients 25 months of age and older.
Procedure code 1-99291 should be used per day for the first 30 to 74 minutes of critical care even if the time spent by the physician is not continuous on that day.
Procedure code 1-99292 should be used per day for each additional 30 minutes beyond the first 74 minutes of critical care for up to 6 units or 3 hours per day. If the number of units is not stated on the claim, allow only a quantity of one.
The following services are denied as part of another procedure when billed on the same day as hospital critical care E/M procedure codes 1-99291 and 1-99292:
Claims for seemingly improbable amounts of critical care (procedure code 1-99292) on the same date may be subject to review to determine if the physician has filed an erroneous claim.
Pediatric Critical Care
Procedure codes 1-99293 and 1-99294 are used to identify pediatric critical care services provided to clients 29 days through 24 months of age.
Pediatric critical care services are comprehensive per diem (daily) care codes for providers personally delivering or supervising the delivery of care of the critically ill infant or child.
Pediatric critical care procedure codes 1-99293 and 1-99294 are denied when billed by any provider on the same day as neonatal intensive care (procedure codes 1-99295 and 1-99296), low birthweight (procedure 1-99298 and 1-99299, and 1-99300), or critical care procedure codes 1-99298 and 1-99299.
Inpatient pediatric critical care (procedure codes 1-99293 and 1-99294) is a per day charge. If an inpatient E/M service is billed on the same day as pediatric critical care, by the same provider, the inpatient E/M services is denied.
Separate charges for any of the following procedure codes are denied as part of another procedure when billed on the same day as pediatric critical care (procedure codes 1-99293 and 1-99294), neonatal intensive care (procedure codes 1-99295 and 1-99296) or intensive (noncritical) low birth weight services subsequent intensive care (procedure codes 1-99298, 1-99299,and 1-99300):
Neonatal Critical Care
Procedure codes 1-99295 and 1-99296 are used to identify neonatal critical care services provided to clients 28 days of age or less.
Procedure code 1-99295 may be considered for reimbursement once per lifetime per critically ill neonate on the date of admission.
Procedure code 1-99296 may be considered for reimbursement once per day per critically ill neonate and is denied when billed on the same day as procedure code 1-99295.
Procedure codes 1-99295 and 1-99296 may be utilized only during the period of time the neonate is considered to be critically ill.
After the neonate is no longer considered critically ill, the E/M procedure codes for subsequent hospital care (procedure codes 1-99231, 1-99232, and 1-99233) may be utilized.
The same provider may bill for no more than 28 days. After the 28th day, providers must bill pediatric critical care codes (procedure codes 1-99293 and 1-99294).
Neonatal intensive care codes are paid once a day regardless of the time that the physician spends with the neonate. Critical care codes billed the same day as neonatal intensive care codes will be denied regardless of provider.
The following codes billed on the same day by the same provider may be paid in addition to neonatal intensive care:
Intensive (NonCritical) Low Birth Weight Services
Those infants that are low birth weight or very low birth weight who no longer meet the definition of critically ill but continue to require intensive observation and frequent services and interventions only available in the intensive care setting, may bill using procedure codes 1-99298, 1-99299, and 1-99300.
Intensive (non critical) low birth weight services (procedure codes 1-99298, 1-99299, and 1-99300) are considered for reimbursement daily for subsequent neonatal (noncritical) services, regardless of the time that the physician spends with the neonate or infant. Utilize the procedure code appropriate for the present body weight and intensity of service required by the neonate or infant.
Newborn Resuscitation
Procedure code 1-99440, newborn resuscitation, should be used by the physician who provides resuscitation care to the high risk newborn. Newborn resuscitation is considered for reimbursement when billed on the same day as neonatal critical care (procedure codes 1-99295 and 1-99296).
Procedure codes 1-99221, 1-99222, 1-99223, 1-99231, 1-99232, and 1-99233 are denied if billed on the same day as procedure code 1-99440.
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