Orthopedic Coding Alert

Question: CPT^® states that a patient must be “critically ill or injured” in order to use critical care codes. Could you briefly explain what “critically ill or injured” means, and give me some examples of conditions that may warrant critical care?

Delaware Subscriber

Answer: According to the CPT^® manual, a critical illness or injury “acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.” In other words, critical care occurs when the patient’s condition is so tenuous that the immediacy of care could affect patient outcome.

You’ll report critical care encounters with 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (… each additional 30 minutes [List separately in addition to code for primary service).

Examples of scenarios in which critical care might be warranted include, but are not limited to:

• Trauma from an automobile accident,
• possible spinal or neck fractures,
• renal failure,
• heart attack,
• stroke, and
• drug/alcohol overdose.

Remember: In order to report critical care codes, the physician must have provided at least 30 documented minutes of critical care time to the patient. The documentation should support the time as well as the critical nature of the patient’s condition. If the care does not exceed 30 minutes, the visit does not warrant 99291 — even if the patient is considered “critical.”

If the physician does not cross the 30-minute threshold, report an E/M service based on the details within the encounter notes.