Pediatric Coding Alert

Often a preemie needs to be transported from a rural hospital to one with a NICU. Or a newborn needs to be sent from one NICU to a hospital where surgery is going to be done. A pediatrician or neonatologist accompanies the baby on these trips, which are either by helicopter or ambulance.

Our doctor is going to be part of a transport team, writes Connie Arnold, billing clerk for Carlos Anaya, MD, a pediatrician and neonatologist in Eldorado, AK. We need to know what procedure code we can use for the doctor going with the critical patient in the ambulance or helicopter to transport the patient from one facility to another.

Critical Care Codes

One answer is to use the critical care codes, says Diane Kirkle, CPC, compliance coordinator for Creighton Medical Associates, the physician-health organization that is part of Creighton University in Omaha, NE. There is no location for the critical care codes, says Kirkle, noting that CPT states that critical care is usually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, respiratory care unit, or the emergency care facility. Patients being transported from NICU to NICU, if they are unstable, quality for critical care. But you must be providing face-to-face critical care to use these codes, Kirkle adds.

Only one doctor for any given time period can provide the critical care, she notes. What if two physicians are on the transport team? Then one can do it one hour, and the other can do it the other hour, she adds. And the blocks of time dont need to be that large. The pediatrician or neonatologist should be sure to use stop and start times when documenting, says Kirkle.

Actually, time is an essential element of the critical care codes. As CPT states, they are used to report the total duration of time spent by a physician providing constant attention to an unstable critically ill or unstable critically injured patient, even if the time spent by the physician providing critical care services on that date is not continuous.

The first hour of critical care should be reported as CPT 99291 . Each additional 30 minutes is reported as 99292. If you spend more time with the patient, you multiply the 99292 code for each 30 minutes.

Note: These codes can only be used when you are providing critical care services. Once youve transported the patient and are no longer by his or her side, you are responsible for getting yourself back home.

Other Alternatives

The critical care codes are what you would use if a child were truly critical -- on assisted ventilation, for example -- says Steven E. Krug, MD, FAAP, head of the pediatric emergency department at Childrens Memorial Hospital and a member of the AAP RBRVS PAC.

Another problem is inter-hospital transport, "which is typically poorly reimbursed, says Krug, who is also specialty advisor for pediatrics to the AMA RUC. Thats why we usually use residents or fellows. Its also why the big medical transport organizations deliver a bill to the receiving hospital at the same time they deliver a patient. The hospital knows if they dont pay it, the company wont bring them patients any more, says Krug.
But Krug does have some suggestions, in addition to the critical care codes (which you may not be able to use if, for example, you are transporting a stable newborn to another hospital for surgery).

Prolonged services codes. These codes (99354 for the first hour, 99355 for each additional 30 minutes) can be used for transport.

Consultation codes. If the pediatrician is seeing a patient in the hospital -- either as a consultant or as the primary physician -- and then transports the patient, the inpatient consultation codes (99251 to 99255) can be used.

Emergency department codes. The case may start in the emergency department, where the pediatrician may be summoned to attend that patient -- who then needs to be transported. In this scenario, you can use the emergency department code -- and you would probably use the highest level: 99285.

Notes: (1) Critical care codes include a number of procedures, such as ventilator management and vascular access procedures. If you bill the critical care codes, reminds Krug, you cannot add these procedure codes. If, however, you bill prolonged services codes, no other procedures are bundled in and you can add them to your fee. (2) Are prolonged services codes always reimbursed for transport? No, says Krug. Unfortunately, correct coding does not guarantee reimbursement.