New Payment Policy: Critical Care in the Emergency Department

Effective with claim dates of service on and after October 30, 2024, critical care services provided as part of an emergency department encounter when the patient is discharged home may be denied reimbursement. These critical care services may be reviewed to determine if the services do or do not meet the requirements for critical care as described in the Current Procedural Terminology (CPT) codebook.

Critical care procedure codes 99291 and 99292, when billed with the following criteria, may be reviewed:

• Revenue code 450 representing an emergency room visit
• Discharge status code 01 indicating the patient was discharged home
• Admit and discharge dates of service are the same or the discharge date is one day beyond the admit date to indicate an encounter spanning midnight

Outpatient facility claims that meet the above criteria may be reviewed and denied reimbursement if the critical care services provided do not meet the requirements for critical care.

To review the details of the new payment policy that will become effective with claim dates of service on and after October 30, 2024, search for the policy “Critical Care in the Emergency Department when Patient is Discharged Home” in the Availity Essentials provider portal.