Pediatric Coding Alert

Question: When pediatricians in a group practice perform critical care individually on the same day to the same patient, may a pediatrician use 99292 if he didn't perform 99291? Also, should I still report these codes if the physicians don't document time?


California Subscriber
Answer: The answers to your questions are yes and no. Yes: Pediatricians who operate under one tax identification number may share same-day critical care responsibilities and bill cumulative group time.

No: If documentation does not include time, you should not code critical care services (99291-99292, Critical care, evaluation and management of the critically ill or critically injured patient ...).

Be careful: You will have to report the same-day critical care services using one claim form. Code +99292 (... each additional 30 minutes [list separately in addition to code for primary service]) is an add-on code to 99291 (... first 30-74 minutes). If you report separate claims for each pediatrician, the insurer will deny the individual 99292 charges. You may have to adjust your group billing protocols to report the different-pediatrician E/M services jointly to the insurer and then back out each physician's portion.

To ensure your pediatricians appropriately capture critical care services, you should teach them about 99291-99292 requirements. Codes 99291-99292 are time-based. Therefore, an auditor would expect to see a time entry documenting either total critical care time or start and stop times.

Detailing the procedures that substantiate critical care, such as chest x-ray interpretation (71010-71020), pulse oximetry (94760-94762), and intubation (43752 and 91105), does not meet the time requirement. Watch out: Don't count time required for doing procedures not included in critical care in total critical care time.

Solution: Go back and review the nursing documentation. The notes could provide the time information you need without altering the medical records.