Your Guide to Pediatric Critical Care
When choosing codes, factor in age, time, guidelines, and bundling rules.
Proper documentation and coding of critical care services depend not only on the Centers for Medicare & Medicaid Services (CMS) and CPT® guidelines, but also the payer (individual payers may have unique critical care requirements). To help ensure you are reporting these services correctly, you must have a solid understanding of pediatric critical care codes, including when to use them and when it’s more appropriate to use the standard, time-based critical care codes 99291-99292.
Note: CMS rules may apply for a child on Medicaid. Best practice is to check with the Medicaid carrier to see if it follows CMS/CPT® rules.
Location Matters Less than You Think
Critical care services usually are provided in a critical care area, such as a coronary care unit (CCU), intensive care unit (ICU), or the emergency department (ED); however, critical care services may be provided in any location, as long as the care meets the definition of critical care. Likewise, just because a patient is in the ICU, CCU, neonatal intensive-care unit (NICU), etc., does not mean you can report critical care. Merely “rounding” to check vitals and to document that an otherwise stable patient is on a ventilator does not meet critical care requirements.
Indicators of Critical Care
Several key performance indicators (KPI) are required to report critical care. Both the illness or injury and the treatment provided must meet critical care requirements. Clinical reassessments and documentation must support the aggregated critical care time for patients over 5 years old, including:
- A complete itemization of the physician’s ongoing interval assessments of the patient’s condition
- Any impairments of organ systems based on all relevant data available to the physician (e.g., metabolic changes and diagnostic results)
- The rationale and timing of interventions
- Patient response to treatment
Pediatric Critical Care Defined
Pediatric critical care codes are reported per day. If a provider from the same group or specialty rounds on the patient later in the day, he or she cannot bill another critical care code for a patient younger than 5 years of age. The applicable code sets include:
Neonatal critical care 28 days or younger
99468 Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger
99469 Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger
A term infant is born after a normal pregnancy, labor, and delivery. The infant has significant respiratory distress and requires NICU admission with intubation and mechanical ventilation. The neonatologist places an umbilical arterial line. Chest X-ray reveals a pneumothorax. The neonatologist additionally places a chest tube.
Correct coding is 99468-25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service and 32551 Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open (separate procedure). Endotracheal intubation (31500 Intubation, endotracheal, emergency procedure) and umbilical artery catheterization (36660 Catheterization, umbilical artery, newborn, for diagnosis or therapy) are bundled with 99468, which represents initial inpatient neonatal critical care for a patient 28 days or younger. Modifier 25 is appended to the critical care code to alert the payer of a significant separately identifiable evaluation and management (E/M) service by the same physician on the same day as another service.
Pediatric critical care 29 days–24 months
99471 Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age
99472 Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age
A former 25-week gestation infant, now 45 days old, remains ventilator dependent. Today, he has increased ventilatory requirements and his perfusion is poor. The provider suspects acquired sepsis. The provider performs a bladder aspiration and lumbar puncture, obtains a blood culture, and begins a course of antibiotics.
Correct coding is 99472, which describes subsequent inpatient global critical care code for a patient who is older than 29 days but younger than 24 months. The bladder aspiration and lumbar puncture are bundled into the critical care.
Pediatric critical care 2-5 years
99475 Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age
99476 Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age
A 5-year-old girl is in a motor vehicle accident, causing blunt trauma to her left side, resulting in splenic laceration, rib fractures, flail chest on the left, and acute respiratory failure. The pediatric critical care physician should report 99475 for initial inpatient critical care.
On day two of her hospital stay, the child develops infiltrates in the left chest and left pleural effusion on chest radiograph. She goes into respiratory arrest and is ventilated. The pediatric critical care physician reports 99476 for subsequent inpatient critical care; all other services are bundled into the critical care.
When reporting critical care services for patients over 5 years of age, use time-based critical care codes.
Critical care for patients over 5 years
99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes
+99292 each additional 30 minutes (List separately in addition to code for primary service)
Proper documentation of time is essential to correctly reporting 99291 and 99292. Use 99291 to report the first 30-74 minutes of critical care and +99292 to report additional 30-minute blocks of time beyond the first 74 minutes of critical care, as shown in Table A.
|Total Duration of Critical Care||Appropriate CPT® Codes|
|Less than 30 minutes||99232, 99233,
or other appropriate E/M code
|30 – 74 minutes||99291 x 1|
|75 – 104 minutes||99291 x 1 and 99292 x 1|
|105 – 134 minutes||99291 x 1 and 99292 x 2|
|135 – 164 minutes||99291 x 1 and 99292 x 3|
|165 – 194 minutes||99291 x 1 and 99292 x 4|
|194 minutes or longer||99291 – 99292 as appropriate|
For example, for critical care time of 76 minutes, report 99291. For critical care time of 110 minutes, report 99291 for the first hour and 99292 x 1 for the additional 36 minutes. Critical care time less than 30 minutes is not reported using critical care codes. Any service less than 30 minutes must be reported using the appropriate ED, inpatient, or other code that best reflects provided services.
The CPT®/CMS Rundown on Critical Care
CPT® and CMS critical care definitions vary. CPT® specifies, “A critical illness or injury in which one or more vital organ systems is impaired such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.” Evidence that criteria were met must be present in the medical record with the physician’s attestation that critical care was provided.
CMS not only requires the illness or injury to be of an urgent or emergent nature, but there must be the added inclusion of high-level treatment(s) and interventions to satisfy critical care criteria:
- CMS criteria for critical care is not met if the emergency physician does not prescribe any pharmacological intervention.
- CMS criteria for critical care is met if other acute interventions (intubation, etc.) are provided as necessary during the course of care.
- CMS critical care is not met if the patient only receives coordination of care and interpretation of studies and is admitted or discharged.
CMS gives several examples that do not satisfy the criteria because medical necessity was not met, or the patient does not have a critical care illness or injury and is not eligible for critical care payment:
- Patients are admitted to a critical care unit because no other hospital beds were available.
- Patients are admitted to a critical care unit for close nursing observation and/or frequent monitoring of vital signs (e.g., drug toxicity or overdose).
- Patients are admitted to a critical care unit because hospital rules require certain treatments (e.g., insulin infusions) to be administered in the critical care unit.
Be Careful Not to Unbundle
CPT® and CMS consider several services to be included (bundled) in critical care time when performed during the critical portion of the service by the same physician(s) providing critical care. Do not report these services separately. Both CPT® and CMS bundle the following services into critical care codes 99291 and 99292:
- Interpretation of cardiac output measurements (93561, 93562)
- Pulse oximetry (94760, 94761, 94762)
- Chest X-rays, professional component (71010, 71015, 71020)
- Blood gases, and data stored in computers (e.g., electrocardiograms [ECGs], blood pressures, hematologic data – 99090)
- Gastric intubation (43752, 91105), transcutaneous pacing (92953)
- Ventilator management (94002-94004, 94660, 94662)
- Vascular access procedures (36000, 36410, 36415, 36591, 36600)
For pediatric critical care for patients under 5 years of age (99468, 99469, 99471, 99472, 99475, and 99476), CPT® and CMS consider several additional services to be included in critical care time when performed during the critical portion of the service by the same physician(s) providing critical care.
All services included in codes 99291-99292, as well as the following, which may be reported by facilities only:
- Administration of blood/blood components (36430, 36440)
- Administration of intravenous fluids (96360-96361)
- Administration of surfactant (94610)
- Bladder aspiration, suprapubic (51100)
- Bladder catheterization (51701, 51702)
- Car seat evaluation (94780-94781)
- Catheterization umbilical artery (36660)
- Catheterization umbilical vein (36510)
- Central venous catheter, centrally inserted (36555)
- Endotracheal intubation (31500)
- Lumbar puncture (62270)
- Oral or nasogastric tube placement (43752)
- Pulmonary function testing, performed at the bedside (94375)
- Initial and subsequent care provided to a critically ill infant or child
- Other hospital care or intensive care services by same group or individual done on same day the patient was transferred to initial neonatal/pediatric critical care
- Readmission to critical unit on same day (subsequent care)
CMS further specifies the relevant time frame for bundling to include the entire calendar day for which critical care is reported, rather than limiting the time to the period the patient is critically ill or injured during that calendar day, as CPT® does.
Bill Separately Reportable Services
When reporting 99291-99292, the critical care clock stops when performing non-bundled, separately billable procedures. Although not an exhaustive list, examples of common, separately reportable procedures that may be performed for a critically ill or injured patient over 5 years old include:
- Cardiopulmonary resuscitation (92950)
- Endotracheal intubation (31500)
- Central line placement (36555, 36556)
- Intraosseous placement (36680)
- Tube thoracostomy (32551)
- Temporary transvenous pacemaker (33210)
- ECG with at least 12 leads w/interpretation and report only (93010)
- Electrical cardioversion (92960)
- Services performed by a transferring individual prior to transfer of the patient to a different individual in a different group (99221-99233, 99291-99292, 99460-99462, 99477-99480)
- Services provided by another individual in another group receiving a patient transferred to a lower level of care (99231-99233, 99478-99480)
- Services provided by an individual transferring a patient to a lower level of care (99231-99233, 99291-99292)
A neonatologist is asked to assume care for a 6-year-old boy in respiratory arrest. She spends 90 minutes providing critical care services to stabilize the child, including endotracheal intubation and placement of a central line.
Correct coding is 99291, 99292, 31500, and 36556. Because the boy is 6 years old, the time-based critical care codes are appropriate. The intubation (31500) and central line placement (36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older) are not bundled into critical care, and may be reported separately.
CMS and CPT® indicate that time is critical to the mission of accurately reporting critical care services, and providers must ensure that they clearly report time for these services in the medical record. Coders and billers must be able to extract the aggregate time to report the appropriate critical care codes. Make sure your providers are documenting accordingly.
For more information on critical care services, refer to MLN Matters® article MM5993, available on the CMS website.
Holly Cassano, CPC, is CEO of ACCUCODE Consulting, LLC, and has worked in practice management, coding, auditing, teaching, blogging, and consulting for multiple specialties for the past 18 years. She writes for codingcertification.org, Tactical Management, Inc., Justcoding.com, Advance for Health Information Professionals, and others. Cassano is a member of the Tampa, Florida, local chapter, for which she has served two terms as an officer. You can reach her at firstname.lastname@example.org and follow her on Twitter@hollycassano.