My neurologists that see patients at a nearby hospital (usually being consulted on ER cases) have a question about requirements for billing Critical Care (99291-99292). I’ve given them the guidelines from the current CPT book that state that "providing medical care to a critically ill, or injured, or post-operative patient qualifies as a critical care service only if both the illness or injury AND the treatment being provided meet the above requirements". They are arguing that at times, the patient’s illness meets the critical guidelines, but no treatment is given. Based on the book guidelines, this would not meet the CC guidelines, but they feel that the intensity of the service/severity of the patient’s condition should still meet the guidelines. Some examples are if the patient is in status epilepticus, myasthenia gravis crisis, hypoxic brain injury due to cardiac arrest, encephalitis. The most common example of when they do meet the CC guidelines is stroke patients who have TPA ordered. Can anyone give any insight or documentation that would agree with their opinion that these patients qualify for CC codes even though they don’t meet the book guidelines?

TIA!!