Topics in Practice Management
CHEST / 141 / 3 / MARCH, 2012 787
during their fi nal hospital admission. Nearly one-third
of patients with advanced cancer who receive Medi-
care die in hospitals, often in ICUs. 1 For most patients
who are hospitalized, death occurs following the with-
drawal or withholding of life-sustaining treatment. 2,3
For these patients who are critically ill, the inte-
gration of palliative care practices and principles
is essential for high-quality critical care. Although
palliative care specialists are available in a growing
number of hospitals, 4 intensivists and other physicians
n the United States, about 20% of Medicare benefi -
ciaries with chronic illness spend time in an ICU
with primary or consultative responsibility for patients
who are critically ill are also expected to provide basic
palliative care, including symptom treatment, commu-
nication about goals of care, and transition planning. 5
Palliative care is an essential part of comprehensive
critical care, with widely available tools and resources
to facilitate the integration of these services. 6-10
Patients who are critically ill often lack the capacity
to make decisions regarding their own care. In these
circumstances, physicians must meet with family
members or other surrogates to determine appro-
priate medical treatments. Such meetings require
Patients with advanced illness often spend time in an ICU, while nearly one-third of patients with
advanced cancer who receive Medicare die in hospitals, often with failed ICU care. For most,
death occurs following the withdrawal or withholding of life-sustaining treatments. The integra-
tion of palliative care is essential for high-quality critical care. Although palliative care specialists
are becoming increasingly available, intensivists and other physicians are also expected to pro-
vide basic palliative care, including symptom treatment and communication about goals of care.
Patients who are critically ill are often unable to make decisions about their care. In these situa-
tions, physicians must meet with family members or other surrogates to determine appropriate
medical treatments. These meetings require clinical expertise to ensure that patient values are
explored for medical decision making about therapeutic options, including palliative care. Meet-
ings with families take time. Issues related to the disease process, prognosis, and treatment plan
are complex, and decisions about the use or limitation of intensive care therapies have life-
or-death implications. Inadequate reimbursement for physician services may be a barrier to the
optimal delivery of high-quality palliative care, including effective communication. Appropriate
documentation of time spent integrating palliative and critical care for patients who are critically
ill can be consistent with the Current Procedural Terminology codes (99291 and 99292) for crit-
ical care services. The purpose of this article is to help intensivists and other providers under-
stand the circumstances in which integration of palliative and critical care meets the defi nition of
critical care services for billing purposes. CHEST 2012; 141(3):787–792
Abbreviations: CMS 5 Centers for Medicare and Medicaid Services; CPT 5 Current Procedural Terminology ;
E/M 5 evaluation and management; RVU 5 relative value unit
Physician Reimbursement for Critical Care
Services Integrating Palliative Care for
Patients Who Are Critically Ill
Dana R. Lustbader , MD ; Judith E. Nelson , MD , JD , FCCP ; David E. Weissman , MD ;
Ross M. Hays , MD ; Anne C. Mosenthal , MD ; Colleen Mulkerin , MSW , LCSW ;
Kathleen A. Puntillo , RN , DNSc ; Daniel E. Ray , MD , FCCP ;
Rick Bassett , MSN , RN , APRN , ACNS-BC , CCRN ; Renee D. Boss , MD ;
Karen J. Brasel , MD , MPH ; Margaret L. Campbell , PhD , RN ;
Therese B. Cortez , MSN , NP , ACHPN ; and J. Randall Curtis , MD , MPH , FCCP ;
for The IPAL-ICU Project
Topics in Practice Management
• How does reimbursement under critical care
codes compare with that under standard evalua-
tion and management (E/M) codes?
• What is the applicability of critical care codes to
the delivery of specifi c components of palliative
care in the context of critical care services?
• What are the limitations on the use of critical
care CPT codes?
What Is the Definition of Critical Care
for CPT Coding and Billing Purposes?
The codes for critical care services in CPT are
99291 and 99292. 13 These are time-based codes—
that is, reimbursement is based on the time spent by a
physician providing critical care, rather than directly
on the level of complexity involved in evaluation and
treatment. As explained in Transmittal 1548 (July 9,
2008) from the Centers for Medicare and Medicaid
Services (CMS), 14 for CPT codes 99291 and 99292,
Critical care is defi ned as the direct delivery by a physician(s)
medical care for a critically ill or critically injured patient. 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.
The CMS goes on to state,
Critical care involves high complexity decision making to
assess, manipulate, and support vital system functions(s) to
treat single or multiple vital organ system failure and/or
to prevent further life threatening deterioration of the
patient’s condition. Examples of vital organ system failure
include, but are not limited to: central nervous system fail-
ure, circulatory failure, shock, renal, hepatic, metabolic,
and/or respiratory failure. Although critical care typically
requires interpretation of multiple physiologic parameters
and/or application of advanced technology(s), critical care
may be provided in life threatening situations when these
elements are not present. Providing medical care to a crit-
ically ill, injured, or post-operative patient qualifi es as a
critical care service only if both the illness or injury and the
treatment being provided meet the above requirements . 14
Code 99291 is used for the initial time period of
service from 30 min up to 74 min. Thirty minutes
is the minimum period of service for the use of this
code; service for , 30 min is to be reported under
E/M codes (eg, subsequent hospital care, CPT codes
99231-99233). Code 99292 is used for each “addi-
tional 30 minutes” of critical care beyond the fi rst
74 min. Thus, if the care requires ? 75 min, the phy-
sician may report time using 99291 plus 99292. Time
spent providing critical care encompasses the total
time in a single calendar day and need not be con-
tinuous. For example, if an intensivist examines a
patient who is critically ill in the morning and returns
later the same day for a family meeting to establish
clinical expertise to ensure that patient values and
beliefs are explored for informed medical decision
making about therapeutic options, including palliative
care. 11 Meetings with families take time, especially
in the ICU, where issues related to the disease pro-
cess, prognosis, and treatment plan are complex, and
decisions about the use or limitation of intensive care
therapies have life-or-death implications.
Inadequate reimbursement for physician services
may be a barrier to the optimal delivery of high-quality
palliative care, including effective communication. 12
However, appropriate documentation of time spent
integrating palliative and critical care for patients
who are critically ill can be consistent with the
Current Procedural Terminology (CPT) codes (99291
and 99292) for critical care services. The purpose of
this article is to help intensivists and other physicians
understand the circumstances in which the integration
of palliative and critical care meets the defi nition of
critical care services for the purposes of these CPT
codes. We provide examples of documentation that
support the CPT critical care codes for services inte-
grating palliative care as part of critical care for patients
who are critically ill (e-Appendix 1 ).
The key questions we address are the following:
• What is the defi nition of “critical care” for the
purposes of CPT codes 99291 and 99292?
• What providers can report time using critical
care CPT codes?
Manuscript received August 11, 2011; revision accepted October 17,
Affiliations : From the Division of Palliative Medicine
(Dr Lustbader), North Shore University Hospital, Manhasset, NY;
the Department of Medicine (Dr Nelson), Mount Sinai School of
Medicine, New York, NY; the Department of Internal Medicine
(Dr Weissman), Medical College of Wisconsin Milwaukee, WI;
the Department of Pediatrics (Dr Hays), Seattle Children’s
Hospital, Seattle, WA; the Division of Critical Care and Palliative
Care (Dr Mosenthal), University of Medicine and Dentistry,
Newark, NJ; the Department of Palliative Medicine (Ms Mulkerin),
Hartford Hospital, Hartford, CT; the School of Nursing (Dr Puntillo),
University of California, San Francisco, San Francisco, CA; the
Critical Care Department (Dr Ray), Lehigh Valley Health Net-
work, Allentown, PA; St. Luke’s Hospital (Mr Bassett), Boise, ID;
the Department of Pediatrics (Dr Boss), Johns Hopkins Hospital,
Baltimore, MA; the Department of Surgery (Dr Brasel),
Froedtert Hospital, Milwaukee, WI; the Department of Nursing
(Dr Campbell), Detroit Receiving Hospital, Detroit, MI; the
Department of Palliative Care (Ms Cortez), Veterans Integrated
Service Network 3, New York, NY; and the Division of Pulmonary
and Critical Care Medicine (Dr Curtis), Harborview Medical
Center, Seattle, WA.
Correspondence to: Dana R. Lustbader MD, Hofstra North
Shore-LIJ School of Medicine, Palliative Medicine, Critical Care
Medicine, North Shore University Hospital, 300 Community Dr,
Manhasset, NY 11030; e-mail: Lustbader@nshs.edu
© 2012 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians ( http://www.chestpubs.org/
CHEST / 141 / 3 / MARCH, 2012 789
the same specialty, and (3) each provider selects a
unique primary International Classifi cation of Diseases
diagnosis code. 18 For example, a pulmonary or critical
care specialist might code as critical care the time spent
in the treatment of dyspnea for a patient with acute
respiratory failure, while a physician from a different
specialty (either from the same group practice or a dif-
ferent group practice) could also code as critical care
the time spent on the same day in a family discussion
of whether to initiate or withhold mechanical ventila-
tion based on the patient’s preferences and prognosis.
How Does Reimbursement Under the
Critical Care Codes Compare With
That Under Standard E/M Codes?
The critical care codes support higher reimburse-
ment than is available for services billed using
standard E/M codes, such as initial inpatient ser-
vice (99221 and 99223) or subsequent hospital care
(99231-99233). The average 2011 Medicare reim-
bursement rate for 99291 is approximately $243.
Each additional 30 min of critical care service is reim-
bursed under 99292 at approximately $122. This con-
trasts with the E/M rate of $105 for the highest
subsequent visit code, level 3, 99233. 19
Other time-based CPT codes are 99356 (fi rst hour)
and 99357 (each additional half hour). For prolonged,
direct, face-to-face time between a physician and
patient, 99356-7 can be used together with an E/M
code such as 99233. The 2011 Medicare reimburse-
ment rate for 99356 is $99. However, the use of
99356 and 99357 for prolonged, direct, face-to-face
service, such as a meeting to discuss treatment options
in relation to goals of care, requires the physical
presence of the patient during the discussion. This is
not possible for many patients in the ICU, whose
consciousness or cognition is impaired by illness or
sedation. By contrast, as set forth in the “Providers’
Discussions with Patients and/or Families about the
Plan of Care (Including the Use or Limitation of
Intensive Care Therapies)” section, patient presence
is not required when critical care codes 99291 and
00292 are used to report time spent by physicians
in family meetings to discuss treatment options for
patients lacking decision-making capacity.
Every CPT code has an assigned physician work
relative value unit (RVU) established by the CMS.
The critical care code 99291 is valued at 4.5, while
a high-level subsequent visit code, 99233, carries
a value of 1.0. The prolonged, direct, face-to-face
code 99356 has a work RVU of 1.5. 20 Appropriately
coding for medical care provided may also impact sal-
aried physicians because many compensation models
include a work RVU component for the determina-
tion of overall physician pay.
goals of care and make treatment decisions (including
decisions to withdraw or withhold life-sustaining
therapies), the time for both visits that day may be
aggregated for reporting with the critical care codes.
Visits on the same day by different providers in the
same practice group (eg, ICU attending during the
day and ICU nighttime attending) may be aggregated
under the name of one of these providers, but the
services reported as the initial critical care time,
billed as CPT code 99291, must be performed by a
single provider, according to the CMS.
Codes 99291 and 99292 may be used to report
time spent providing critical care for a patient who is
critically ill not only in the ICU but also in any hospital
setting, including the ED or a regular medical and/or
surgical inpatient unit. For example, the critical care
codes might be used to report time spent providing
qualifying services during a rapid response outside
the ICU. Such services could include intensive pal-
liative care (eg, emergent treatment of dyspnea with
opioids and benzodiazepines) as part of a rapid crit-
ical care response on a medical and/or surgical fl oor
for a patient with organ failure (eg, respiratory fail-
ure) or an emergent discussion with the family about
whether to initiate or withhold cardiopulmonary
resuscitation during a rapid response. As discussed
later in this article, inclusion of the family discussion
as critical care time would require, among other ele-
ments, that the physician be immediately available
(ie, proximate) to the patient for the entire duration
of time reported as critical care services.
What Providers Can Use Critical Care
CPT Codes to Report Their Services?
Throughout the United States, the critical care codes
may be used not only by critical care specialists but
also by physicians in any specialty. 15 Most states also
allow the use of critical care codes by advanced
practice providers such as nurse practitioners, with
reimbursement rates of 85% of the physician fee
schedule. 16,17 Be aware that split or shared service
performed by a physician and a qualifi ed nonphysi-
cian provider of the same group practice is not
reportable as a critical care service; only cumulative
critical care time provided by physicians within a
group is reported as such. Multiple specialists have
the opportunity to use critical care codes to report
time spent providing services in a given day. Physi-
cians self-designate their specialty on their Medicare
enrollment application. Providers in each distinct
specialty (eg, pulmonary disease, critical care, general
medicine, palliative medicine) can use critical care codes
to report services meeting the criteria for these codes
provided that (1) the times of the day reported by these
providers do not overlap, (2) the providers are not in
Topics in Practice Management
should be identifi ed, and the total time spent in the
meeting should be documented. For the purposes
of codes 99291 and 99292, critical care does not
include giving emotional support to the family or
answering questions that do not directly contribute
to the treatment of the patient or decision making.
In documenting the family meeting, this distinction
must be clearly drawn in order to support the use
of the critical care codes. Caution is advised since
family meetings that do not satisfy the critical care
coding requirements may lead to code revision or
removal, further eroding fi nancial incentives to pro-
vide comprehensive patient- and family-centered care.
Time spent in physician-family discussions (in the
absence or presence of the patient) about the use
or limitation of cardiopulmonary resuscitation (ie,
whether to attempt resuscitation or not attempt
resuscitation [a do-not-resuscitate order] in the event
of an arrest) is consistent with the defi nition of crit-
ical care according to the criteria described in this
article for CPT codes 99291 and 99292 and sum-
marized in Table 1 . The same criteria would also
apply to discussions in connection with medical deci-
sion making about the use or limitation of treatments,
including vasoactive medications, mechanical venti-
lation, renal replacement therapy, artifi cial nutrition
and hydration, automatic implanted cardiac defi bril-
lators, or tracheostomy.
The use of the critical care codes is not limited to
in-person communications, but can also include tele-
phone discussions with family or other surrogates
if the discussion contributes directly to the care
and treatment of the patient and if the physician
involved in the discussion is either physically pre-
sent in the ICU or immediately available to the
patient at the time of the call. In addition, if the
patient has the capacity to participate, communication
with the patient’s family or other surrogate decision
maker can still be reported as critical care time pro-
vided that the patient is present for the discussion
and treatment options are discussed.
Many physicians fi nd it helpful and effi cient to
use a documentation template for family meetings
(or other services) that enumerates the elements
required to support reimbursement, while leaving
space to describe selected aspects of the discus-
sion in more depth; examples of such templates are
readily available and easily adapted for local use. 21 The
time spent documenting services in the medical record
is included in critical care time for the purposes of
the CPT codes, provided the physician is immedi-
ately available to the patient as noted previously.
Management of Distressing Symptoms
All physicians, including those caring for patients
who are critically ill, have a professional obligation
What Is the Applicability of the Critical
Care Codes to the Integration of
Specific Components of Palliative Care
for Patients Who Are Critically Ill?
Key components of palliative care that are often inte-
grated with critical care include (1) communication
and decision making about treatment options in relation
to the patient’s prognosis and preferences (including,
if appropriate, the option to limit intensive care ther-
apies), and (2) management of distressing symptoms
during critical illness. The use of the critical care
codes in connection with these activities is discussed
in the next sections.
Providers’ Discussions With Patients and/or
Families About the Plan of Care (Including the
Use or Limitation of Intensive Care Therapies)
The critical care CPT codes can be used to report
time spent in obtaining information from or providing
information to the patient (see Table 1 ). Recognizing
that the patient who is critically ill or injured often
is incapacitated and physicians must therefore rely
on a family member or other surrogate for medical
decision making, the critical care codes also allow
physicians to report time spent in meetings with sur-
rogates under the following circumstances: (1) the
patient lacks the capacity to participate directly in
the discussion and decision making, and (2) the dis-
cussion is necessary for decision making about med-
ical treatment. The medical record must contain
clear documentation of these elements, according
to the CMS. The physician should also document
the treatments under discussion, which might include
life-sustaining treatments that the surrogates and
physicians must decide to withhold, withdraw, or con-
tinue. In addition, the participants in the meeting
Table 1— Requirements for Using Critical Care Codes
for Family Discussions 14
a. Physician is near patient room or on the unit so that the
physician is immediately available to patient.
b. Patient is unable or lacks capacity to participate in medical
decision making, and the family discussion is necessary for
c. Patient has organ failure.
a. Patient is unable or lacks capacity to make medical decisions.
b. The necessity to have the discussion (i.e. patient deteriorating
and need for discussion of treatment options with family).
c. Medically necessary treatment decisions for which the
discussion was needed (i.e. continuing vs withdrawing mechanical
ventilation, initiation of vasoactive medications, institution of
artifi cial nutrition and hydration, do-not-resuscitate order).
d. Time spent in preparation for and during family meeting
discussing treatment options and goals of care. Do not include
time providing grief or bereavement support.
CHEST / 141 / 3 / MARCH, 2012 791
Transmittal 1548 14 provides an example of a ser-
vice that should not be reported as critical care:
A dermatologist evaluates and treats a rash on an ICU
patient who is maintained on a ventilator and nitroglycer-
ine infusion that are being managed by an intensivist. The
dermatologist should not report a service for critical care.
In contrast, a physician called emergently to treat
acute dyspnea and agitation for a patient who is criti-
cally ill may meet the criteria required for report-
ing critical care service under CPT codes 99291 and
Physicians Practicing in Teaching Hospitals
Time spent independently by physician trainees
providing critical care services may not be included
in the total time reported by the attending physician
under the critical care codes. A teaching physician who
is present for the entire period of time that the trainees’
services are delivered may report this time under the
critical care codes with appropriate documentation, but
cannot include time spent teach ing, reviewing educa-
tional material, or performing procedures. The teach-
ing attending’s documentation must be suffi ciently
robust to stand alone in supporting the use of the crit-
ical care codes by that attend ing. It may be helpful to
document treatment changes that resulted from this
service (eg, addition of an opioid infusion for dyspnea,
entry of a do-not-resuscitate order, or discontinuation
of hourly fi nger sticks for blood glucose monitoring).
Counseling and Bereavement Support
For the purposes of CPT codes 99291 and 99292,
critical care services reported by a physician may
not include services delivered by other health-care
professionals such as chaplains and social workers.
Additionally, time spent by the physician providing
emotional support to a grieving family member is not
reportable as critical care time.
Because of regional variations in the interpreta-
tion of reimbursement policies, local coding experts
may provide guidance on the appropriate use of crit-
ical care codes for services integrating palliative care
in the management of patients who are critically ill.
Careful attention must be paid to documentation
requirements supporting the use of critical care
codes so as not to jeopardize their use for reimburse-
ment of time spent providing this important patient-
Palliative care is an integral part of critical care for
patients who are critically ill, regardless of prognosis,
to address pain and other symptoms causing patient
distress. The effective management of symptoms not
only serves the goal of comfort but is also associated
with physiologic benefi ts, including reduction of
myocardial oxygen consumption, synchrony with
mechanical ventilatory support, and improved pulmo-
nary function. For the patient who is critically ill,
symptom assessments are frequent, and management
may be particularly complex and time-consuming
because of hemodynamic instability, organ dysfunc-
tion, delirium, anxiety, and the concurrent use of
multiple other medications. Physicians use critical
care codes to report the integration of symptom
and delirium management with critical care man-
agement, including continuation or weaning from
intensive care therapies. There must be clear docu-
mentation that the clinical activity involves the
delivery of critical care to a patient who is critically ill
Limitations on the Use of the
Critical Care Codes
Physicians should be aware of limitations on the
use of the critical care codes.
For the purposes of codes 99291 and 99292, critical
care services must be medically necessary. Necessity
is not established by the patient’s mere presence in
the ICU (as opposed to another hospital unit), nor is
it suffi cient that the patient (in the ICU or another
setting) is receiving life-sustaining treatment such
as mechanical ventilation or vasoactive medications.
The physician’s care must itself be medically necessary
(and meet all aspects of the defi nition of critical care
service according to the CMS: “The treatment and
management of the patient’s condition, while not
necessarily emergent, shall be required, based on the
threat of imminent deterioration.”
Providing Care for the Patient Who Is Critically
Ill vs Providing Critical Care Services
Not all care provided to a patient who is criti-
cally ill meets the defi nition of critical care services
for the purposes of CPT codes 99291 and 99292.
As explained in CMS Transmittal 1548, 14
Providing medical care to a critically ill patient should
not be automatically deemed to be a critical care ser-
vice for the sole reason that the patient is critically ill
or injured. While more than one physician may provide
critical care services to a patient during the critical care
episode of an illness or injury each physician must be man-
aging one or more critical illness(es) or injury(ies) in whole
or in part.
792 Download full-text
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text of critical illness, the delivery of palliative care
may include complex symptom management in the
face of organ failure. Palliative care also includes
family discussions for medical decision making about
treatment options, including decisions to initiate,
continue, or limit intensive care treatments. Through
the use of appropriate documentation, physicians can
use critical care billing codes to optimize reimburse-
ment for fulfi lling the mandate to integrate pallia-
tive care as part of comprehensive critical care for all
patients who are critically ill and critically injured.
Financial /nonfi nancial disclosures: The authors have reported
to CHEST that no potential confl icts of interest exist with any
companies/organizations whose products or services may be dis-
cussed in this article.
Additional information: The e-Appendix can be found in the
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