Description
Critical Care is the direct delivery by a provider of medical care for a critically ill/injured patient in which there is acute impairment of one or more vital organ systems, such that there is a probability of imminent or life-threatening deterioration of the patient’s condition. It involves high complexity decision-making to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition.
Policy
Blue Cross Blue Shield of North Carolina (Blue Cross NC) will reimburse facility critical care services according to the criteria outlined in this policy.
Reimbursement Guidelines
Critical care services may be subject to denial or reimbursed based on the appropriate E&M when all of the following are applicable:
- The critical care service is performed during an Emergency Department encounter (045x)
- Member is discharged to home on the same or next day (discharge status 01)
Critical care represents services provided for conditions that acutely impair one or more vital organ systems in such a way that there is a high-probability of imminent or life-threatening deterioration of the condition. Services provided that do not meet the definition of a critical care service, but the member happens to be in a critical care or other specialized care unit, should be reported using another appropriate E/M code.
Note: This policy does not apply to critical care services that include observation or intensive care (ICU).
Billing and Coding
Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.
| Code | Description |
|---|---|
| 99291 | Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes |
| 99292 | Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) |
| 045x | Emergency Room – General Classification (revenue code) |
| Discharge Status 01 | Discharge to Home or Self Care (Routine Discharge) |
Related Policy
Evaluation and Management Services
References
American Medical Association, Current Procedural Terminology (CPT®)
Centers for Medicare & Medicaid Services, CMS Manual System, Medicare Claims Processing Manual 100-04, and NCCI Policy Manual
Healthcare Common Procedure Coding System
History
1/1/2026 New policy developed. RPOC approved. Notification on 11/1/2025 for effective date 1/1/2026. (ss)
Application
These reimbursement requirements apply to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, Healthy Blue + Medicare (HMO-POS D-SNP), and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services.
This policy relates only to the services or supplies described herein. Please refer to the Member's Evidence of Coverage (EOC) for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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