Pediatric Coding Alert

Peds patients must still meet critical illness, injury standards.

When you’re reporting critical care services for your pediatric patients, some of the claims will require pediatric critical care codes 99468 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger) through 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).

If the patient is 6 years or older, however, you’ll revert to traditional critical care codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (… each additional 30 minutes [List separately in addition to code for primary service]).

You need to remember, however, that the patient must still meet the parameters for critical care in order to report 99468-99476.

“The same clinical definition for critical care services apply for the adult, child, and neonate,” confirms Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare in Lansdale, Pa. “The variability is the time threshold per age; per day versus per hour.”

This means knowing the definition, for coding purposes, of critically ill or injured — regardless of the patient’s age or the code set you’re choosing from. Check out this quick reminder on what CPT® really means by “critical.”

Use This Critically Ill/Injured Definition

Pediatric patients who receive critical care must meet the definition of critically ill or injured, just as an older patient would.

“Critically ill or injured implies that there is a risk of loss-of-life or loss-of-function/further loss-of-function of a major organ or organ system, with an acute or exacerbated presentation of the condition,” explains Joshua Tepperberg, CPC, senior coding analyst at caduceus inc., in Jersey City, N.J.

Some examples of potential critical care scenarios include, but are not limited to, patients suffering from:

• respiratory failure,
• cardiac failure,
• kidney failure,
• metabolic failure,
• brain injury,
• major traumas, or
• a combination of the above or with other co-morbidities.

In short: The criteria are that the patient has to be critically ill or injured such that there is a threat to life and limb applies to all of the critical care codes, explains Donelle Holle, RN, President of Peds Coding, Inc, and a healthcare, coding, and reimbursement consultant in Fort Wayne, Ind.