Pediatric Coding Alert

Question: What is the difference between neonatal critical care (99468-99476) and intensive care (99477-99480) and their appropriate applications?

AAPC Forum Participant

Answer: You should assign a code from 99468-99476 (Initial/Subsequent inpatient neonate/pediatric critical care, per day, for the evaluation and management of a critically ill neonate/infant or young child…) or 99477-99480 (Initial/Subsequent intensive hospital care, per day, for the evaluation and management of the neonate/recovering very low birth weight/recovering low birth weight/recovering infant…) using the following decision-making process.

First, ask if the patient’s care is intensive or critical. CPT^® guidelines for pediatric critical care are the same as those for adult critical care, which means that the encounter must meet the following criteria:

• The illness or condition “acutely 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.”
• The provider exercises “high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.”

You should code care for patients that meet these criteria with 99468-99476; you should code “services … for infants and neonates who are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring, and constant observation by the health care team under direct supervision of the physician or other qualified health care professional” with 99477-99480.

Second, ask the patient’s admission status. Codes 99468, 99471, 99475, and 99477 can only be used for the initial day of inpatient care. All other codes must be used for subsequent day care.

Third, ask the patient age/weight. The critical care codes are age-specific for patients aged less than 28 days (99468, 99469, 99477); 29 days to 24 months (99471, 99472); and 2 years to 5 years (99475, 99476). For pediatric patients older than 5, you will use the adult critical care codes (99291, +99292).

The initial day intensive care code, 99477, is specifically for use with patients 28 days and younger. You would code any subsequent day intensive care services from 99478-99480 depending on the child’s weight at the time of the service.

Putting it all Together: Your pediatrician oversees initial day services to a normal newborn who developed signs of hypothermia and who needs interventions along with observations and intensive monitoring. You would use 99477 to code this service.