Pediatric Coding Alert

But ignore location as a deciding factor.

“Critical care is … determined … by the nature of the care being delivered and the condition of the patient.” So said Jessica Miller, CPC, CPC-P, CGIC, Manager of Professional Coding for Ciox Health in Alpharetta, Georgia in her presentation “NICU and Peds - Coding for Everyday Challenges,” delivered during HealthCon 2020.

That means “the patient must meet the same clinical criteria as the adult critical care codes,” Miller added. But what are those criteria? And how does the nature of pediatric critical care differ from adult critical care?

Here are the answers to these two key critical care questions. But first, it is important to understand that critical care can happen anywhere.

Critical Care Does Not Necessarily Mean ICU Care …

One coding myth about critical care that should be immediately dispelled is that critical care always means care performed in the neonatal intensive care unit (NICU), pediatric ICU (PICU), or the ICU. In fact, “critical care is not determined by the location in which the care is being delivered,” according to Miller.

While “critical care is typically performed in a hospital setting, there is nothing in the book that states it is limited to the hospital setting,” adds Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

“Most, but not all, patients that are critically ill are transported to the hospital,” Holle continues. “Every now and then, however, we can use medications and treatments in the office setting to bring them out of a critical care situation. Typically, these are respiratory issues, though they can be neurologic as well,” Holle adds.

… but it Does Mean Asking These Critical Questions …

Regardless of setting, to determine whether a patient meets the critical care clinical criteria, you should first “ask and answer the following questions about the service. If the answer is ‘no’ to any of these, do not code as critical care,” Miller cautions. Those questions, as Miller asks them, are:

• Does the record demonstrate the patient has an acute impairment of one or more vital organ systems and has a high probability of imminent or life-threatening deterioration?
• Does the record demonstrate “High-complexity decision making to assess, manipulate, and support vital system function(s); to treat single or multiple organ system failure; and/or prevent further life-threatening deterioration”?
• Does the record demonstrate that a “sudden, clinically significant or life-threatening deterioration in the patient’s condition” would result if the provider failed to initiate certain specific and urgent interventions?

If the answer to each of Miller’s questions is yes, then you can apply critical care codes 99468-99469 (Initial/ Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger); 99471-99472 (Initial/ 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); or 99475-99476 ( … 2 through 5 years of age) for critically ill patients through the age of 5 in the hospital setting.

Once your patient reaches the age of 6, you will then report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), using +99292 (… each additional 30 minutes …) for time over and above 75 minutes.

Coding alert: These codes can be used regardless of age outside of the hospital setting. The 24-hour codes are for NICU or PICU care; in the office setting, you can only use the hourly codes.

Documentation tip 1: “Critical care does not require history, exam or MDM [medical decision making], but it should be indicated by statements such as ‘patient presents in critical condition due to severe respiratory distress,’” says Holle. Additionally, “for the critically ill child, you need documentation of an assessment and a plan along with documentation of others involved in the care.”

Documentation tip 2: “For 99291-+99292, you must document the amount of time spent in critical care by the provider using statements such as ‘total time in critical care 38 min,’” Holle offers as a reminder.

This means recording stop and start times, “especially in inpatient settings, because the total time there is often not continuous,” Miller notes. It also means “documenting family discussions with and without the patient present, as they are appropriate to count as critical care time,” Miller adds. In fact, all time spent in care for the patient who requires critical care is counted. This includes the discussions with other providers or staff as well.

… and Knowing What Is, and Is Not, Bundled

A second challenge for peds coders is knowing which services are bundled into the pediatric codes and how they differ from the services bundled into 99201-+99292. For while 99468-99469, 99471-99472, and 99475-99476 bundle many of the same services, four key services are not bundled into the hourly critical care codes.

Services bundled into all critical care codes include:

• 36000, 36410, 36415, 36591, 36600 (vascular access procedures);
• 43752, 43753 (gastric intubation);
• 71045, 71046 (interpretation of chest X rays);
• 92953 (temporary transcutaneous pacing);
• 93561, 93562 (interpretation of cardiac output measurements);
• 94002-94004, 94660, 96662 (ventilatory management); and
• 94760, 94761, 94762 (pulse oximetry);

along with the interpretation of blood gases, and collection and interpretation of physiologic data (e.g. electrocardiograms [ECGs], blood pressures, and hematologic data).

The four peds exceptions: Not included in 99291-+99292 — but bundled into 99468-99469, 99471-99472, and 99475-99476 — are 31500 (Intubation, endotracheal, emergency procedure), 51100 (Aspiration of bladder; by needle), 51701 (Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine), and 51702 (Insertion of temporary indwelling bladder catheter; simple (eg, Foley)).

Don’t forget to stop the clock: Whenever your pediatrician does provide a separately reported service that is not bundled into 99291-+99292, such as 31500, you cannot report time spent on that service toward time counted for 99291-+99292, Miller reminds coders.