Pediatric Coding Alert

Hint: Observe the 71-month threshold for 99291, 99292.

When a pediatrician has to provide critical care for one of her patients, you cannot just report 99291/99292 and send the code in for payment.

Why? There are different code sets for younger patients who receive critical care, and still different code sets for neonates. Read on to get all the info you’ll need to file each of your pediatric critical care claims correctly.

Px 6 and Older Fall Under Standard CC Codes

When a provider performs critical care for children 72 months (6 years) and older, you should report the standard critical care codes when the visit meets critical care parameters, according to Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare in Lansdale, Pa.

These codes are 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]).

According to CPT^® 2017, “Services for the critically ill or critically injured child 6 years of age or older would be reported with the time-based critical care codes (99291, 99292).”

Break Down Peds CC Codes by Age

When a patient is younger than 72 months and requires critical care, however, there are a few coding options:

• For patients 28 days and younger, you’ll report 99468 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger) or 99469 (Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger), Falbo confirms.
• For patients 29 days to 24 months, you’ll report 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) or 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).
• For patients 25 months through 71 months old, you’ll report 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) or 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).

Note Full-Day Status of Peds CC Codes

As you likely noticed in the descriptors, the codes for 99468-99476 are per day, rather than by the hour and minute. The codes also pay much higher than the standard 99291 and 99292 codes, because they reflect a full-day commitment, explains Donelle Holle, RN, President of Peds Coding, Inc, and a healthcare, coding, and reimbursement consultant in Fort Wayne, Ind.

Pediatric critical care codes “have very high RVUs [relative value units] associated with them, and the work performed in those codes is for 24 hours; no different than a regular hospital admission code or subsequent hospital care code,” Holle says. “These codes have the same criteria as the regular critical care codes, but they can only be reported by one physician, where the 99291 and 99292 codes can be reported by multiple physicians on the same date.”  

Remember: Pediatric codes are age-specific, “so physicians need to watch the age of the child carefully, reminds Holle.

Include Documentation on Peds CC Claims

Since the 99468-99476 codes are so high-paying, you’ll want to be extra sure you have all the documentation you need when you submit the claim the first time.

For pediatric critical care, “the documentation should always adequately describe the patient and the circumstance,” according to Suzan Hauptman, CPC, CEMC, CEDC, senior principal of ACE Med group in Pittsburgh, Pa. “Because these codes indicate an age, it should be evident within the notes as to the age of the infant [or child] and the critical nature of the problems at hand.”

Holle agrees, saying “it is always a good idea to state why the child is critically ill [in the notes].”

Example: A good peds critical care note might read “Patient presents today in severe respiratory distress.” Holle also recommends that at the end of the note the physician states something like: “Total time in critical care due to respiratory distress 45 min.” That clearly indicates to the payer that the child was critically ill, Holle explains.