Billing and Coding for Critical Care: How to Maximize RVUs Without Getting Audited

You spend hours managing critically ill patients, but if your documentation doesn't support your billing, you're leaving money on the table—or worse, exposing yourself to audit risk. Here's what every ICU APP needs to know about billing and coding.

Critical Care Time: The Foundation

Critical care billing (99291, 99292) is time-based, which makes it unique—and uniquely audit-prone.

What Qualifies as Critical Care?

A critical illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration.

Examples:

• Septic shock
• Respiratory failure on mechanical ventilation
• Acute MI with hemodynamic instability
• Status epilepticus
• Multiorgan failure

Not critical care:

• Stable patient on ventilator (routine vent management)
• Observation status without acute threat
• Post-procedure monitoring (unless complications)

Time Requirements

Critical point: You must spend at least 30 minutes of critical care time to bill 99291. 29 minutes = cannot bill critical care.

What Counts as Critical Care Time?

Included:

• Direct bedside patient care
• Time spent reviewing data (labs, imaging) related to critical care
• Discussing case with consultants (related to critical illness)
• Family discussions about critical illness
• Documentation of critical care (during the encounter)
• Medical decision-making requiring your immediate personal attention

Not included:

• Time spent on procedures separately billable (central line, intubation)
• Teaching time
• Travel time to/from unit
• Time when another provider is billing for the same patient
• Waiting time (for tests, for bed, etc.)

Procedure Coding in the ICU

Certain procedures are bundled with critical care; others bill separately.

Bundled (Don't bill separately):

• Pulse oximetry
• Chest X-ray interpretation
• Blood gas interpretation
• Gastric intubation
• Temporary transcutaneous pacing
• Ventilator management

Bill Separately:

• Central venous catheter placement (36555-36556)
• Arterial line (36620)
• Endotracheal intubation (31500)
• Chest tube insertion (32551)
• Lumbar puncture (62270)
• CPR (92950)—only one provider per code

Documentation Tip

For separately billable procedures, document:

• Indication
• Consent (or emergency circumstances)
• Technique (sterile prep, ultrasound guidance)
• Complications (or absence thereof)
• Post-procedure assessment

Documentation Essentials for Critical Care

Must Include:

1. Nature of critical illness (be specific—"septic shock secondary to pneumonia," not just "critical")
2. Total critical care time (in minutes—"I spent 65 minutes of critical care time")
3. Activities during that time (assessment, orders, family discussion, etc.)
4. Medical decision-making demonstrating complexity

Sample Documentation:

"This patient has septic shock secondary to urinary source, requiring mechanical ventilation and vasopressor support. I spent 75 minutes of critical care time today, which included direct bedside assessment, ventilator adjustments, hemodynamic management, reviewing imaging and laboratory results, discussing prognosis with family, and coordinating care with nephrology regarding CRRT initiation. Central line placement (35 minutes) billed separately."

Time Documentation Options:

• Start and end times: "Critical care provided 0800-0915 (75 minutes)"
• Total time: "75 minutes of critical care time exclusive of separately billable procedures"

Shared/Split Billing (When Physicians Are Involved)

When you provide critical care and the attending also sees the patient, only one provider bills critical care.

Rules:

• One provider bills for the total critical care time
• Time from both providers can be combined IF: both met the patient and both provided critical care services
• Documentation must clearly reflect who did what and total time

APP-Specific Considerations:

• In many practices, the APP documents their critical care, and the physician bills (combining time if applicable)
• Some practices have APPs bill independently (at 85% rate)
• Know your group's billing structure

Modifiers You Need to Know

• Modifier 25: Significant, separately identifiable E/M service on same day as procedure
• Modifier 59: Distinct procedural service
• Modifier AI: Principal physician of record (rarely APP-relevant)

Common Audit Triggers

Auditors look for:

1. Billing critical care for stable patients (documentation must support acuity)
2. Overbilling time (billing 120 minutes on a day with many patients)
3. Missing time documentation (must state minutes)
4. Double-billing (two providers billing critical care for same patient at same time)
5. Bundled procedures billed separately
6. Inconsistent documentation (note says "stable," then bills critical care)

Improving Your RVU Capture

Legitimate Strategies:

• Document all qualifying time (family meetings often forgotten)
• Bill procedures separately when appropriate
• Use 99292 for each additional 30 minutes (many stop at 99291)
• Capture all patients seen (missed charges are common)
• Ensure accurate coding (work with your billing team)

What NOT to Do:

• Inflate time
• Document critical care for non-critical patients
• Bill for time spent on teaching
• Duplicate billing with attendings without clear documentation

Working with Your Billing Team

Build a relationship:

• Ask for feedback on your documentation
• Request periodic coding audits
• Learn from denied claims
• Attend billing education sessions

Advocate for yourself:

• If you're undervaluing your work, you're hurting your compensation
• If your documentation supports more RVUs, work with billing to capture them

Sample Critical Care Day Documentation

HPI: 58 y/o male with septic shock secondary to necrotizing pancreatitis, currently on mechanical ventilation (day 3), norepinephrine 0.15 mcg/kg/min, vasopressin 0.04 units/min, CRRT for AKI.

Critical Care Time: I spent 95 minutes of critical care time today (7:15 AM - 8:50 AM), exclusive of separately billable procedures. This included direct bedside assessment, vent management for worsening hypoxemia (increased PEEP from 12 to 14, decreased tidal volume), hemodynamic optimization (weaning norepinephrine as tolerated), coordination with surgical team regarding need for repeat debridement, and extensive family meeting (45 minutes) regarding prognosis and goals of care.

Procedures: Central line exchange over wire (separately documented, 36584).

Billing: 99291, 99292 x 2 (95 minutes total)

The Bottom Line

Billing correctly is about documentation that reflects the work you actually do. Underbilling undervalues your contribution; overbilling creates legal risk. Master the coding rules, document thoroughly, and ensure you're capturing the full value of your critical care work.

Your documentation is your proof. Make it bulletproof.