Critical care first hour
CPT 99291 covers the first hour of critical care a physician provides to a critically ill or injured patient who requires constant bedside attention and complex medical decision-making.
This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
NCCI bundling edits
Loading bundling edits…
Billing tips
Document exact start and stop times for critical care to the minute, excluding time spent on separately billable procedures
Impact: Critical for audit defense; lack of specific times is the #1 reason for downcoding from 99291 ($265.56) to lower-level E&M codes ($100-150), resulting in $115-165 loss per encounter
Bill 99291 for 30-74 minutes of critical care time; use 99292 for each additional 30 minutes beyond the first 74 minutes
Impact: Billing 99291 for less than 30 minutes results in automatic denial; must bill appropriate E&M level instead. At 75 minutes, failing to add 99292 loses $139.12 in reimbursement
Exclude time spent on separately billable procedures (intubation, central lines, ventilator management codes) from total critical care time calculation
Impact: Including procedure time in critical care time creates unbundling issues that trigger audits and potential recoupment of 100% of payment ($265.56 per occurrence)
Document the critical illness or injury affecting one or more vital organ systems and the high probability of imminent deterioration
Impact: Medical necessity documentation is essential; vague documentation like 'patient in ICU' without specific critical illness leads to denials and downcoding to 99232-99233 (loss of $85-145 per visit)
Use place of service code 21 (inpatient hospital) or 23 (emergency department) appropriately, as 99291 cannot be billed in office settings (POS 11)
Impact: Incorrect POS codes trigger automatic denials; facility vs non-facility designation affects rate ($265.56 non-facility vs $205.72 facility, a $59.84 difference)
For multiple physicians of different specialties providing critical care same day, ensure each documents separate, distinct critical care activities
Real billers contribute denial patterns and appeal strategies for this code. Once 5+ reports come in, you’ll see live aggregated data here — the only place this exists, free.
Get the free Revenue Protection Toolkit — the denial triggers, modifier pitfalls, and bundling conflicts that quietly cost you reimbursement. Instant download.
Help build the field knowledge
MedPayIQ gets smarter as billers contribute. If you've had this code denied, share what happened so others learn from it. Anonymous, no patient info.