Can You Bill 99285 and 99291 on the Same Day?
Yes, under Medicare, when the ED visit came first and the patient only later needed critical care. The record must show the visit was medically necessary and separate and distinct from the critical care, and modifier 25 must go where your MAC wants it.
Written by Salman Saeed, CEO and Co-Founder · Reviewed by a Certified Medical Coder · 
In short: an ED visit and critical care can both be billed for one date when the visit came before the patient needed critical care and shares no work with it. If critical care began on arrival, bill critical care alone.
Can You Bill 99285 and 99291 on the Same Date?
Yes, under Medicare, when the ED visit came first and the patient only later needed critical care. Chapter 12, section 30.6.12.6 of the Medicare Claims Processing Manual allows both on one date when the record shows the earlier visit happened before the patient needed critical care, was medically necessary and was separate and distinct from the critical care.
If the patient needed critical care from the moment of arrival, you bill critical care and not a later ED visit by the same group. The rest of this post is how to tell which situation you have, where modifier 25 goes and what to write in the chart.
What Three Things Must the Record Show?
- The other E/M visit was provided before the critical care, at a time when the patient did not need critical care.
- The services were medically necessary.
- The services were separate and distinct, with no duplicative elements from the critical care provided later in the day.
Section 30.6.12.8 repeats all three as the documentation requirement. CMS applies the rule regardless of practitioner specialty or group affiliation, so it covers one physician doing both and two physicians in the same group, one on each service.
The general rule it sits against is in section 30.6.12.6 itself: when the same physician, or physicians of the same specialty in one group, see a patient more than once on a date, only one E/M is reported unless the visits are for unrelated problems. Critical care after an earlier ED visit is the carved-out exception.
Which Codes Do You Bill in Each Situation?
| What happened | What to report |
|---|---|
| ED work-up finished, patient stable. Hours later the patient deteriorates and needs 30 or more minutes of critical care | The ED level for the earlier visit plus 99291 (and 99292 if time reaches 104 minutes). Two services, both documented |
| Patient arrives critical, is resuscitated and stabilized, then gets more ED work | Critical care only. ACEP's critical care FAQ says only one is reported when critical care was delivered on arrival |
| Critical care time totals under 30 minutes | No critical care code. Report the appropriate E/M, usually the ED level by decision making |
| Commercial patient, ED visit and critical care on one date | CPT allows both without regard to order, per ACEP. Some payers want modifier 25 on the non-critical E/M. Check the payer's policy |
The ED level itself is chosen the usual way, from decision making. See how to pick the right ED E/M level. Critical care is chosen by time and the reference pages for 99291 and 99292 have the minute thresholds.
Where Does Modifier 25 Go?
Modifier 25 placement needs attention. Chapter 12 says practitioners must use modifier 25 on the claim when reporting critical care in this situation, and ACEP's FAQ says CMS designated modifier 25 when both are reported on one date by the same group. The MLN booklet MLN006764 puts modifier 25 on the E/M service code. Confirm with your MAC which line it wants. For a non-Medicare patient, ACEP says CPT allows both without regard to order, and some payers may want modifier 25 on the non-critical E/M.
On the CMS-1500, modifiers go in Item 24D, up to four per line. Whichever line your MAC names, get the answer in writing from the MAC's provider contact and keep it with the coding policy. The modifier 25 page covers the modifier more generally.
What Does a Claim Look Like for an ED Visit That Turns Critical?
A Medicare patient arrives at 09:40 with abdominal pain. The physician examines, orders labs and a CT, and has a stable work-up by 11:15. At 12:20 the patient becomes hypotensive and confused, and the physician delivers critical care for 34 minutes, then 28 more at 14:05.
If the second stretch had run 70 minutes instead of 28, the total would be 104 minutes and 99292 would be added once. The note must make the sequence obvious to a reviewer who was not there.
What Should the Note Say?
- The ED evaluation as its own entry: what was found, what was ordered, and a statement that the patient was stable and not critically ill at that time.
- The event that changed the patient's condition, with the time it happened.
- The reason the patient met the critical care definition: an acute impairment of one or more vital organ systems with a probability of imminent or life-threatening deterioration.
- The total critical care time, which CMS says is what must be documented. Start and stop times are not required.
- A statement that the critical care time excludes separately billed procedures.
- A line that the critical care did not repeat work already counted in the ED visit.
The companion post on how to document critical care time covers the time statement in more detail.
Why Does the Claim Deny?
| Code | What X12 says | Usual cause here |
|---|---|---|
| CO-97 | The benefit is included in the payment for another service already adjudicated | ED visit paid, critical care read as duplicative because timing was unclear |
| CO-4 | The procedure code is inconsistent with the modifier used | Modifier 25 on the line the MAC did not expect |
| CO-150 | The information submitted does not support this level of service | No total time in the note, or no sign the earlier visit came first |
The practitioner MUE for 99291 effective October 1, 2026 is 1 per date, so a second 99291 line for the same patient and date denies. Fix the modifier or the note, then resubmit or appeal within the window in the denial notice. The NCCI edits page covers how edits are read.
Does the Hospital Bill It the Same Way?
No. On the hospital claim, CMS section 160.1 of chapter 4 applies a 30 minute minimum for 99291, packages 99292, and has the hospital bill an ED visit when it provides less than 30 minutes of critical care. The facility ED visit level is set by the hospital's own guideline, covered in how hospitals set ED facility levels.
How Does Nucleus Align Handle Same-Day ED and Critical Care?
Our medical coding team includes AAPC and AHIMA certified coders who read the timing in the chart before both codes go out, and we send claims within 24 hours of charge entry and work denials within 48 hours. See emergency medicine billing for the full ER workflow, or book a call.
- Medicare Claims Processing Manual, chapter 12 (sections 30.6.12.2, 30.6.12.6, 30.6.12.8) · CMS
- MLN006764 Evaluation and Management Services · CMS
- Medicare Claims Processing Manual, chapter 4 (section 160.1) · CMS
- Critical care FAQ · American College of Emergency Physicians
- Medicare NCCI medically unlikely edits · CMS
- Claim adjustment reason codes · X12
We check every rule, code and deadline against the official source. See our editorial policy.
Common Questions
Straight answers from the team that does the work.
Ask a billing lead directly. A 20-minute call, Monday to Friday, 9am to 5pm Eastern.
01Can you bill 99285 and critical care 99291 on the same date?
Under Medicare, yes, if the record shows the ED visit came before the patient needed critical care, was medically necessary and was separate and distinct from the critical care. If critical care began on arrival, report critical care and not a later ED visit by the same group.
02Where does modifier 25 go when billing an ED visit and critical care?
Sources disagree. Chapter 12 section 30.6.12.6 says to use modifier 25 on the claim when reporting these critical care services, while MLN006764 puts modifier 25 on the E/M code. Confirm with your MAC which line it wants, and follow the payer's policy for non-Medicare patients.
03What if critical care happened first and the patient needed more ED care after?
Report critical care only. ACEP's critical care FAQ says that when critical care is delivered on arrival and the patient is later stabilized, the same physician or group reports either the ED visit or the critical care, not both, even if more ED services follow.
04Can two physicians in the same group each bill, one the ED visit and one critical care?
Yes, under Medicare. Section 30.6.12.6 allows both services regardless of specialty or group affiliation when the three documentation conditions are met. The earlier visit must precede critical care, be medically necessary and be separate and distinct, with no duplicated elements. Document each physician's role.
Talk to a Billing Lead.
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