Your Critical Care Reimbursement: How to Optimize “Out-of-the-Box”

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Clinician, There is Value in What You Do


In all likelihood, the Critical Care services you provide have the potential to substantially contribute toward your reimbursement. Based on the 2018 Medicare Physician Fee Schedule, Critical Care time (30 to 74 minutes) is reimbursed at $226.80 per encounter.(1) Considering 8.1% of emergency room visits have claims processed for Critical Care time, properly charting your service here can optimize the return for the service you provide.(2) This article will show you how to succeed with the basics of Critical Care documentation as well as how to navigate its nuances. Optimize your charting skills and you can excel in your reimbursement in this area.

Reflect on the work you do and the impact on your reimbursement will come alive.

If you work 15 shifts a month and average 2.25 patients per hour, you serve 3,645 patients annually (based on a nine hour shift length). Within this frame-work and taking into account the above 8.1% national average, that’s 295 patients who require your Critical Care time. Thus, the potential reimbursement derived from your Critical Care services is around $67,000 annually. For an emergency group serving 54,440 patients per year, this figure translates to $1,000,000 annually. Additionally, many private insurers will reimburse higher, so your potential reimbursement with Critical Care is likely greater.


Strengthen Your Focus: The Difference is in the Details

Critical Care time billing is one area where your charting can make all the difference. As an emergency clinician, you likely put a lot of time and effort into areas involving quality patient care, continuing medical education and medical staff relationships. As you strive to excel, be sure not to overlook the importance of your charting. Like many other activities you invest your time in, achieving high-quality documentation requires your attention too. Moreover, your reimbursement relies on it.

Although the guidelines for Critical Care time have remained relatively unchanged for years, many emergency medicine physicians still fall short in realizing their potential in this area. The key to success resides in mastering the basics as well as recognizing the subtle nuances. Knowledge leads to application and application is what will ultimately optimize your reimbursement. Stay focused to accomplish what only you can do.

Start with the Basics: It All Builds from Here

“I spent 30 minutes of critical care time with this patient. This does not include time spent on separately reported billable procedures.”  If you’ve read the previous articles in this Critical Care reimbursement series, you’ve seen this charting example before. Your documentation is the key. When the encounter warrants, you must have an appropriate Critical Care statement to succeed in your reimbursement.

Critical Care encounters involve patients who possess a critical illness or injury which “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.”(3) Reflect on this during your next shift — you’ll quickly realize that many cases qualify for Critical Care.


Be mindful of the services you provide as well as the aggregate amount of time you spend in Critical Care. Frequent actions that count toward Critical Care time involve your discussions with paramedics and/or family members, review of computer record data, interpretation of Pulse ox/chest X-ray/ABG results, discussion with primary and specialty physicians, and your time spent with charting. Document these, alongside an appropriate critical care statement and you can fully optimize your reimbursement. Start with this strong foundation and you will succeed.

Navigate the Nuances and Excel in Your Critical Care

Once you’ve mastered the basics, you’re well positioned to learn the novel details of Critical Care time. These areas include Critical Care service less than 30 minutes, Advanced Practice Provider application and Critical Care that crosses over midnight.

Understand the intricacies here and avoid the pitfalls. Sharpen your documentation skills and you can fully optimize your Critical Care reimbursement.

Critical Care Time Under 30 Minutes
  • “I spent 10 minutes of critical care time with this patient. This does not include time spent on separately reported billable procedures.”
  • “I spent 20 minutes of critical care time with this patient. This does not include time spent on separately reported billable procedures.”

Yes, these statements can play a pivotal role in regard to your reimbursement. All of your Critical Care charting helps to provide insight into the acuity and complexity of a case — even your documentation of Critical Care time that is less than 30 minutes. While neither of the above statements generates a specific Critical Care charge, both can still be very useful to your coders for reimbursement purposes.

Your documentation of Critical Care time less than 30 minutes can help substantiate an encounter being coded as a level 5 rather than a level 4 Evaluation and Management visit. Your charting in this area allows your coders to recognize that there is an element of high risk within a case. This can assist your coders in assigning the appropriate CPT code.

In regard to Emergency Medicine and CPT code reimbursement:

Level 4 encounter:       CPT 99284      3.32 RVUs  =  $119.52

Level 5 encounter:       CPT 99285      4.89 RVUs  =  $176.04

These figures are based on 1 RVU = $36 according to the 2018 Medicare Physician Fee (precise amount, geographic specific). Thus, $56.52 is the potential difference realized by properly documenting the details of your service. When you appropriately provide the details in your charting, your coders have the information they need to be complete.

Therefore, the next time you have a patient who presents with acute MI and goes off promptly to the cardiac cath lab, or respiratory distress from moderate to severe asthma, or hypotension that corrects with IV fluids, be sure to document your time in Critical Care — even if this is less than 30 minutes. Your documentation does make a difference. Appropriately charting your service can go a long way toward realizing your proper reimbursement.

Beyond empowering your coders, there is another important reason to document Critical Care time less than 30 minutes. If your charts are audited, these statements show you have been providing a range of Critical Care (i.e. 10, 20, 30, 45, 75 minutes). In providing this detail, you demonstrate that you are providing high-acuity care across a range of patient encounters, not just the Critical Care resulting in a specific charge. In the practice of emergency medicine, your care is unique and tailored to each patient. So, why not detail your efforts? Be sure to note all of the service you provide.

Your Colleagues in Critical Care: Advanced Practice Providers

Physician Assistants and Nurse Practitioners can potentially bill for critical care time. Two caveats to this: 1) State, hospital and insurance company eligibility rules may apply. 2) The time an Advanced Practice Provider (APP) claims as having spent in Critical Care time must be separate from the physician’s time of care.(4) Thus, the time claimed cannot be the total time “shared” between the two providers. The time documented in Critical Care must be spent solely by the APP or the physician.

Here’s a useful example involving Critical Care time between two clinicians: An APP is managing a 58-year-old male with chest pain. The patient is a poor historian and his past medical history is complicated. As the supervising physician, you discuss the management with the APP, briefly see this patient and chart your note.

A CTA chest is ordered and the patient is found to have extensive pulmonary emboli. The APP spends 45 minutes in Critical Care time in the course of obtaining history from the paramedics, reviewing computer records, placing medical orders, talking with the radiologist, ordering IV heparin and consulting the intensivist. While awaiting an ICU bed, the patient develops hypotension. At this point, you intervene in this patient’s management.  You spend 30 minutes in Critical Care time by way of re-evaluating the patient, ordering IV pressors, consulting with the interventional radiologist and re-discussing the case with the ICU physician. While the shared Critical Care time between the two emergency providers in this case is 75 minutes, the Critical Care statement that you (the physician) charts should reflect only 30 minutes. Your documentation of Critical Care time should only indicate your individual time spent —not the total combined time between you and your APP colleague.

Be Attentive: Critical Care that Crosses over Midnight

Critical Care services must be reported for a single calendar date. This being noted, if you appreciate the details here, you can make real strides toward optimizing your reimbursement. If your provision of Critical Care is performed continuously and crosses over midnight, then the Critical Care time you document can be applied to the pre-midnight date. That is, you can report 75 minutes of Critical Care time, even if 15 minutes of this care crosses over past midnight, as long as your care is provided continuously. Recall that 75 minutes is an important service time through which your coders can submit billing for both CPT 99291 (Critical Care 30 to 74 minutes) and CPT 99292 (Critical Care 75 to 104 minutes).

In regard to disrupted (non-continuous) Critical Care that occurs after midnight, your provision of all such Critical Care is considered new for the post-midnight date and should be reported separately. Thus, 25 minutes of pre-midnight Critical Care cannot be combined with 15 minutes of non-continuous Critical Care that occurs post-midnight. On the upside, if 30 minutes (or more) of your Critical Care service occurs separately on both sides of midnight, this caveat allows you to potentially reimburse twice for Critical Care (CPT 99291) within a single patient encounter.(5)

Your documentation should describe those surrounding circumstances. For example:

  • “I spent 45 minutes of critical care time for this patient on July 28th, 2018. This does not include time spent on separately reported billable procedures.
  • At 00:35 am, while awaiting an ICU bed, the patient developed bradycardia and required additional critical care interventions. Both transcutaneous pacing and a dopamine drip were initiated. I re-discussed the case with Dr. Jones, the intensivist.
  • I spent 30 minutes of critical care time for this patient on July 29th, 2018. This does not include time spent on separately reported billable procedures.”
Put Your Knowledge to the Test

Critical Care Quiz – Do you have what it takes to excel in your Critical Care? Review these three questions and check your answers below.

1. Which of the following is required for a patient encounter to qualify for Critical Care Time?

A. Ambulance arrival and unstable vital signs

B. Consultation with specialty physician(s)

C. Full admission to an inpatient bed

D. A high probability of imminent or life-threatening deterioration

E. An advanced criteria diagnosis


2. Which of the following is true in regard to Critical Care time?

A. Critical Care time is only valuable at 30 minutes or beyond.

B. Advanced Practice Providers cannot bill for Critical Care time.

C. Critical Care time always ends at and begins after midnight.

D. A Critical Care statement is not necessary if the risk and complexity are obvious.

E. Your time spent with charting can be applied toward Critical Care.


3. True or False? “Behavioral Health Encounters involving patients who present with suicidal ideation cannot qualify for Critical Care reimbursement.”

Your Critical Care Answers Delivered
  1. D. A “high probability of imminent or life-threatening deterioration” is required for an encounter to qualify for Critical Care Time. Stable vital signs do not preclude a case from reimbursement in this area. Additionally, a patient can even be discharged home, and their encounter can still qualify (though uncommon, this does occur). Lastly, Critical Care Time does not rely on your concluding findings or diagnosis. Although the labs, CT scan, and LP may all be negative for a confused, elderly patient ultimately diagnosed with “influenza A and dehydration,” such a case can still qualify for Critical Care Time.
  2. E. Your charting does count toward Critical Care Time – it plays an essential role in facilitating patient care. Remember, all of your Critical Care statements are valuable. They assist your coders in assigning the appropriate CPT codes. Additionally, they provide you with a record outlining your overall Critical Care if you are audited. In regard to Critical Care that crosses over midnight, all continuous care can be applied to the pre-midnight date. However, once care becomes non-continuous, it should be applied to your post-midnight care. Finally, Critical Care Time can never be implied, it must be documented by the clinician. Be mindful of the role you have.
  3. False. Cases involving mentally ill patients can indeed qualify for Critical Care Time. A couple of practical (and hypothetical) examples of encounters involving suicidal patients: 1) A 35-year-old male presents combative and agitated. He requires restraints, multiple doses of haldol/ativan, completion of a certificate, and serial exams. 2) A 18-year-old female presents with an overdose attempt of an anti-psychotic medication. Her care involves discussion with the paramedics, review of labs and EKGs, consultation with poison control, completion of a certificate, and serial exams. Critical Care Time applies in both of these above scenarios. Don’t overlook the value of your service.


 Three Take-Away Pearls to Boost Your Practice
  • “I spent 30 minutes of Critical Care Time with this patient. This does not include time spent on separately reported billable procedures.”  =>  Keep in mind Critical Care’s  marquee statement. In order to reimburse optimally, your proper documentation is a must.
  • Advanced Practice Providers can bill for their Critical Care Time in many instances. => Encourage your APP colleagues to be attentive with their Critical Care charting.
  • Continuous Critical Care that crosses over midnight can be applied to your Critical Care Time.  => Once it become non-continuous, post-midnight Critical Care Time should be aggregated and reported separately.

This completes our three part series on Critical Care reimbursement. You now have all the tools you need to succeed. Simply keep in mind there is great value in the Emergency Medicine services you provide. Strive to optimize your charting in Critical Care, and the appropriate reimbursement will follow. Your documentation can make all the difference.


  1. 2018 National Physician Fee Schedule Relative Value File, GPCI18, National Physician Fee Schedule Relative Value File Calendar Year 2018, MCR-MUE-Practitioner Services. Published by CMS. Effective: April 1, 2018.
  1. CMS – 2016 Medicare Utilization Data by Specialty 93 – National: For Claims  Processed with 2016 Dates of Service filed by June 30, 2017
  1. AMA Current Procedural Terminology (CPT) 2018 Professional Edition. 4th ed. Revised 2017: 23-25.
  1. : Transmittal 1548 / MLN Matters Number: MM5993: July 2008.
  2. : Reimbursement FAQs => Critical Care FAQs; Updated 5/26/15. (Resourced May 31st, 2018).


Dan Magdziarz, DO, is an attending ED physician practicing at Palos Hospital. His teaching, quality and reimbursement endeavors seek to promote excellence in Emergency Medicine. Share your interests and comments: [email protected]; EDPMA: QCDC.

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