Pediatric Coding Alert

To report care complexity and medical decision-making accurately for pediatric and neonatal patients receiving long-term hospital care, providers should be prepared to apply critical care, subsequent care and add-on prolonged physician service codes, coding experts stress. Patients who are long-term hospitalization candidates in pediatric facilities often include children and neonates with life-threatening illnesses, injuries or congenital anomalies who need critical care services, so pediatricians should know when to apply the new and revised critical care codes (99293-99296) listed in CPT 2003. (See the December 2002 Pediatric Coding Alert for more on these codes.)

Report 99293-99296 if patients are less than 2 years old and if they meet CPT's definition of "critical," says Shirley Fullerton, CMBS, CPC, CPC-H, academic director for the Medical Association of Billers in Las Vegas and a coder for MedQuist, a national Internet coding and transcription company based in New Jersey. In its critical care services section, CPTspecifies that "a critical illness or injury impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition." Physicians should remember that codes 99293-99296 are global and report these codes only once per day, per critical care patient, Fullerton notes. For critically ill patients more than 2 years old, apply CPT 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the first 30 to 74 minutes of critical care and +99292 (... each additional 30 minutes [list separately in addition to code for primary service]) to report additional blocks of time of up to 30 minutes each beyond the first 74 minutes. Use 99291-99292 to reflect the time the physician spends administering constant critical care to a particular critically ill or injured patient. For instance, if a pediatrician spends 40 minutes discussing the care of a critically ill burn victim with the patient's family, the physician would report 99291. Subsequent Care Codes Reflect Therapy Response For noncritical care patients, use the subsequent hospital care codes, depending on the level of care as reflected in the history, physical exam and medical decision-making, for services the physician provides after the initial hospital admission, says Richard Molteni, MD, FAAP, a neonatologist and member of the American Academy of Pediatrics (AAP) national committee on coding and nomenclature (COCN). The subsequent hospital care codes are:

99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of three key components. Usually the patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit.
99232 ... Usually, the patient is responding inadequately to therapy [...]