Critical care billing in the pediatric realm has particular nuances of which those who care for children should be aware. There are age-based Current Procedural Terminology (CPT) codes for children who have not yet reached their sixth birthday. A child requiring critical and highly complex medical decision making before his/her sixth birthday may be billed using one of these three categories:
• Neonate: Use codes 99468 (initial critical care day) and 99469 (subsequent critical care day) up to and including the 28th day of life (DOL) (date of birth = DOL 0).
• Infant: From the 29th DOL up to the day before the second birthday, use codes 99471 (initial critical care day) and 99472 (subsequent critical care day).
• Preschooler: From the date of the second birthday until the sixth birthday, use codes 99475 (initial critical care day) and 99476 (subsequent critical care day).(1)
In order to use these critical care codes, the patient must be critically ill or injured. For the purpose of coding, the definition of critical illness for children is the same as for adults. A critical illness or injury must acutely impair one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration.
Some patients admitted for pediatric critical care do not meet this criterion. In these cases, alternative CPT codes should be used. For neonates younger than age 29 days who are not critically ill but who nevertheless require intensive observation, frequent interventions, or other intensive care services, 99477 is the appropriate middle-tier initial hospital care code. Subsequent coding for sick infants with these care requirements is based on the patient’s present body weight: 99478 (<1,500 grams), 99479 (1,500-2,500 grams), and 99480 (2,501-5,000 grams). Infants who do not require even this degree of intervention or monitoring should be coded as routine initial (99221, 99222, or 99223) or subsequent (99231, 99232, or 99233) hospital care as appropriate. Once the patient’s weight exceeds 5,000 grams, subsequent hospital care codes should be used.
A clinical scenario will help to clarify these issues. A three-week-old male infant was admitted (99468) a week ago to the intensive care unit (ICU) with sepsis and multisystem organ failure. While still ventilated and on pressors in the ICU, he reaches DOL 29. Although code 99469 (subsequent neonatal critical care) is used on DOL 28, on DOL 29 code 99472 should be used because it is the subsequent critical care code for ages 29 days to 23 months. After a few more days the infant is much improved, and is off mechanical ventilation, oxygen, and pressors, but still requires antibiotics, total parental nutrition, and frequent suctioning. The clinician feels that the infant, although not critically ill, is too ill to transfer to the general pediatrics ward and still requires frequent interventions. His current weight is 3,250 grams. The appropriate billing code is 99480. Additionally, if the infant improves, is moved from the ICU to a general care team, and subsequently becomes critically ill again during the same hospitalization, requiring readmission to the ICU, a subsequent critical care code of 99472 should be used. The initial pediatric critical care codes can be billed only once during each hospitalization, no matter how many times a child is readmitted to the ICU.(2)
These age-based bundled critical care codes do not require that the time spent evaluating the child on the unit be included in the documentation, since time is not a criterion. Note also that these codes can be billed only by a single individual and only once per day, no matter how many visits are made by the same physician or a physician in the same group. It is important to explicitly consider those procedures that are bundled as well as those not bundled under the daily codes. These were reviewed in a previous Coding Corner.(2)
Critical care providers may be called on to provide interfacility transport of critically ill or injured children. CPT codes 99466 (initial 30-74 minutes) and 99467 (each additional 30 minutes) are used to report hands-on care during transport by a physician of a critically ill pediatric patient aged 24 months or younger. Care begins at the time the physician accepts face-to-face responsibility for the patient and ends when responsibility is relieved by the receiving facility. Procedures bundled under adult critical care codes (99291 and 99292) are also bundled under pediatric transport codes and therefore should not be separately reported. Note, however, that procedures bundled under the pediatric and neonatal critical care codes—but not the adult critical care codes—are separately reported if performed by the transporting physician. This includes such commonly performed procedures as arterial and central venous catheterization, intubation, and transfusion of blood products.(3)
Critical care practitioners may also provide non-face-to-face direction of specialized emergency personnel during interfacility transport of a critically ill patient aged 24 months or younger. These services are reported using codes 99485 (first 30 minutes) and 99486 (each additional 30 minutes). Time includes all two-way communication between the control physician and the transport team before transport, at the referring facility, and during transport. Medical direction of less than 15 minutes as well as all procedures performed by the transport team should not be separately reported.(3)
Another coding issue relevant only to pediatrics is the use of modifier 63. This modifier, when appended to a procedure code, acknowledges the additional technical challenges and complexity of performing procedures in very small patients. The code is used only for patients with a current body weight of 4 kilograms or less, and cannot be used with any evaluation and management codes or for any procedures that can be performed only in neonates. Note also that procedures such as lumbar puncture, arterial catheterization, and venous catheterization are frequently bundled under critical or intensive care codes. In these cases, use of modifier 63 would also not be appropriate.(3)
1. American Medical Association. CPT (Current Procedural Terminology) 2016 Professional Edition. Chicago, IL: American Medical Association; 2016.
2. AAP Committee on Coding. Coding for Pediatrics 2016: A Manual for Pediatric Documentation and Payment. 21st ed. Elk Grove Village, IL: American Academy of Pediatrics; 2016.
3. Dorman T, Britton F, Brown D, Munro N, eds. Coding and Billing for Critical Care: A Practice Tool. 6th ed. Mount Prospect, IL: Society of Critical Care Medicine; 2014.