Pediatric Coding Alert

Critical care services (99291, critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes, and 99292, ... each additional 30 minutes) have been redefined in CPT Codes 2001. These codes can now be used only when the child is, indeed, critically ill. The descriptors in the codes themselves have not changed, and neither have the code numbers. But the introductory verbiage in the CPT manual has been substantially altered, with additions that clearly restrict the use of these codes. And HCFA has increased the relative value units (RVU) accordingly: total work RVUs are 5.71 for 99291, and 2.92 for 99292 for 2001, up from 5.09 and 2.51, respectively.

The new language in CPT 2001 includes several elements that are key to understanding when to bill for critical care services. These include:

1. Critical Injury. CPT 2000 defined critical care as the delivery of care for a critically ill or injured patient. CPT 2001 inserts the word critically before injured, so there is no confusion about this: the patient must be critically injured.

2. Life Threatening. CPT 2000 provided that a critical illness or injury impairs one or more organ systems to the extent that the patients survival is jeopardized. CPT 2001 honed this language to state that the organ system impairment must be such that there is a high probability of imminent or life-threatening deterioration in the patients condition. In the introduction, CPT 2001 inserts the phrase life threatening before the word deterioration.

3. Vital Organ System Failure. The examples listed under what could constitute vital organ system failure in the critical care introduction are much more specific in CPT 2001 than in CPT 2000. But, these are just examples and are not definitive. The list itself is similar in 2000 and 2001.

4. Advanced Technologies. CPT 2000 said critical care may require extensive interpretation of multiple databases and the application of advanced technology. On the other hand, CPT 2001 uses the more demanding phrase typically requires:

Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life-threatening situation when these elements are not present.

5. Illness and Treatment. The new descriptor in CPT 2001 clearly states that the patients condition is not the only determining factor when using the critical care codes, but the treatment being provided as well. This is the one worrisome thing about the new verbiage, says Joel Bradley, MD, FAAP, a member of the American Academy of Pediatrics (AAP) coding and reimbursement [...]