Pediatric Critical Care

You’re Probably Familiar with Critical Care Codes 99291-99292, But Have You Experienced Coding Intricacies for Pediatric Patients 24 Months of Age or Younger?

By Patricia Champion, CPC
The same definition for critical care applies to all age groups—adult, child, and neonate. CPT^® defines critical care as the direct delivery by a physician of medical care for a critically ill or critically injured patient. The critical illness or injury acutely impairs one or more vital organ systems to the point of a high probability of imminent or life-threatening deterioration in the patient’s condition. Critical care involves high complexity medical decision making to assess, manipulate, and support vital organ system failure and to prevent further life-threatening deterioration of the patient’s condition.
CPT^® examples of vital organ system failure include, but are not limited to, the following:

• central nervous system failure,
• circulatory failure,
• shock,
• renal failure,
• hepatic failure,
• metabolic failure, and/or
• respiratory failure

The Centers for Medicare and Medicaid Services (CMS) Medical Review has two criteria: clinical condition and treatment. The clinical condition criterion states, “There is a high probability of sudden, clinically significant or life threatening deterioration in the patient’s condition which requires the highest level of physician preparedness to intervene urgently.”
CMS treatment criterion reports, “Critical care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent personal assessment and manipulation by the physician. Withdrawal of or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient’s condition.”
CPT^® lists the management, monitoring, and treatment of the patient involved in neonatal and pediatric critical care including:

• Enteral and parenteral nutritional maintenance
• Metabolic and hematologic maintenance
• Respiratory, pharmacologic control of the circulatory system
• Parent/family counseling
• Case management services
• Personal direct supervision of the health care team in the performance of cognitive and procedural activities
• Neonatal Critical Care

CPT^® codes 99295-99296 are used to report services provided by a physician directing the care of a critically ill neonate through the first 28 days of life. The codes are reported once per day, per patient. Care starts with the admission and ends once the neonate is no longer considered to be critically ill. Also included in the neonate critical care codes are immediate preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions.

• Critically ill neonates require the following:
• Cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated)
• Continuous or frequent vital sign management
• Laboratory and blood gas interpretations
• Follow-up physician re-evaluations
• Constant observation by health care team under direct physician supervision

Neonatal Intensive Care Services

CPT^® codes 99298, 99299, 99300 are used to report services subsequent to the day of admission provided by a physician directing the continuing intensive care of the low birth weight newborn who does not meet the definition of critically ill, but continues to require intensive observation, frequent interventions, and other intensive services. They may only be reported once per calendar day, per patient and are global days with the same services bundled as outlined under 99293-99296.

Pediatric Critical Care

CPT^® codes 99293-99294 are used to report services provided by a physician directing the care of a critically ill neonate/infant 29 days through 24 months of age and are reported once per day, per patient. Care starts with the date of admission and ends once the infant or young child is no longer considered to be critically ill.
To report critical care services provided in an outpatient setting, emergency department or office for neonates and pediatric patients up through 24 months of age use the timed Critical Care Services codes 99291-99292. If the same physician provides critical care services for a neonatal or pediatric patient in both the outpatient and the inpatient settings on the same day, only report the appropriate Neonatal or Pediatric Critical Care codes for all critical care services provided on that day.
The Neonatal and Pediatric Critical Care codes, 99293-99296, include the bundled procedures listed in the hourly Critical Care codes (99291-99292), as well as the following bundled procedures. (Report separately any performed services that are not listed):

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