Pediatric Coding Alert

Question: When a physician provides critical care to a neonate, and the patient turns 29 days old, should the first pediatric critical care service be billed as an initial visit because it falls under a new code set, or as a subsequent visit because the physician has been managing the patient all along?

Louisiana Subscriber

Answer: Beginning on day 29, you’ll use code 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). Let’s take a look at why.

Technically, while there is a different code set for infants over the age of 29 days, the work involved matches that of a subsequent visit, not an initial one. Also, the evaluation and management (E/M) Guidelines for Inpatient Neonatal and Pediatric Critical Care codes 99468-99476 state that these codes “represent care starting with the date of admission for critical care services.”

So, let’s say the patient’s initial visit was at 18 days old. That would call for code 99468 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger), then 99469 (Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger) for subsequent care until the patient is 29 days old. As long as the admission was continuous, and the patient moved into the next age range of 29 days to 24 months before the end of critical care services, you would bill 99472 for any subsequent inpatient critical care services provided to the patient starting on day 29.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC