99291
HospitalCMS status: ACritical care, evaluation and management of the critically ill or critically injured patient, first 30-74 minutes on a given date. CMS 2026 wRVU 4.50. The highest-paying inpatient E/M code; reserved for true critical care delivery.
Drop 99291 into a scenario to see how unit volume rolls up to annual wRVUs, gross collections, and bonus.
Open in calculator →When to use it
Use 99291 only when the patient meets CMS critical care criteria: a critical illness or injury that acutely impairs one or more vital organ systems, with a high probability of imminent or life-threatening deterioration, AND the care delivered is high-complexity decision-making to prevent further organ failure. Real examples: septic shock with vasopressor titration and lactate trending; respiratory failure requiring ventilator management decisions; status epilepticus with antiepileptic loading; acute MI with thrombolytic decision-making; post-cardiac-arrest care. The time threshold is 30 minutes minimum on the calendar day; time under 30 minutes is billed as a subsequent visit (99231-99233) instead.
Documentation checklist
- ✓Document the critical illness explicitly: name the vital organ system(s) at imminent risk and the specific intervention preventing deterioration.
- ✓Document total critical care time on the calendar day. Time can be summed across multiple visits in the same calendar day. Minimum 30 minutes for 99291.
- ✓List the activities that count as critical care time: bedside care, family discussion related to treatment decisions, review of imaging and labs, discussion with consultants, documentation of the critical care visit itself, separate-from-bedside review and decisions.
- ✓Time that does NOT count: time on separately billable procedures (e.g., central line placement billed separately), routine rounds, teaching time.
- ✓Procedures bundled into critical care time and not separately billable: gastric intubation (43752), temporary transcutaneous pacing (92953), ventilator management (94002-94004), vascular access for routine venipuncture (36000, 36410), pulse oximetry (94760-94762), arterial blood gas interpretation (82803).
- ✓Procedures that unbundle and can be billed separately: central line placement (36556), endotracheal intubation (31500), CPR (92950), thoracentesis (32555), lumbar puncture (62270).
Common pitfalls
- !Billing 99291 for a patient who is not critically ill. Most common audit finding. Routine ICU rounds on a stable patient do not meet critical care criteria.
- !Billing 99291 plus a same-day subsequent visit code (99232 or 99233) for the same physician and patient. Critical care time and subsequent-visit time on the same day are not separately billable; pick one.
- !Counting time on separately billed procedures as critical care time. The two cannot overlap.
- !Failing to document the specific vital organ system at risk and the intervention. "ICU rounds, patient improving" does not support 99291.
- !Time-based billing without documenting the total time. Audit-proof language: "Total critical care time on date of service: 50 minutes, including 25 minutes at bedside titrating norepinephrine and reviewing arterial line waveforms, 15 minutes reviewing imaging and labs with concurrent decision-making, and 10 minutes in family meeting discussing prognosis."
- !Counting routine medical-student or resident teaching as critical care time.
Payer notes
Medicare and commercial payers pay 99291 at a significantly higher rate than the highest-MDM subsequent care code (99233 at 2.00 wRVU vs 99291 at 4.50 wRVU). Use the code only when documentation supports critical illness; the disparity drives aggressive auditing. CMS Comparative Billing Reports rank clinicians on 99291 rates relative to specialty peers. Documentation that names the at-risk organ system, the intervention, and the time meets the standard.