Neonatal and Pediatric Critical Care Billing

2015 - 1 February – Team Science
Randi M. Trope, DO, MBA; Marvin Hall, MD, CPE
This article centers on the nuances of neonatal and pediatric critical care billing.
Billing for neonatal and pediatric critical care applies to critically ill patients who have not reached their sixth birthday. Unlike adult critical care billing, pediatric billing is not time based. The billing code options are as follows:

 Neonatal inpatient critical care (0 -28 days), first day:  99468
 Neonatal inpatient critical care (0 -28 days), each subsequent day: 99469

 Pediatric inpatient critical care (29 days – 24 months), first day: 99471
 Pediatric inpatient critical care (29 days – 24 months), each subsequent day: 99472

 Pediatric inpatient critical care (2-5 years), first day:  99475
 Pediatric inpatient critical care (2-5 years), each subsequent day: 99476

The exact age of the patient on the day you provide care is vitally important. A 28-day-old patient admitted to either the pediatric intensive care unit (PICU) or neonatal intensive care unit (NICU) for critical care services can be billed to code 99468 for the day of admission. However, the next day (when the patient is 29 days old), the billing code would be 99472. The same principle holds true as a patient turns two years old (use 99471/99472 the day before the birthday and then 99475/99476 the day of the birthday and later). Again, as a patient turns six years old, you would use the appropriate pediatric critical care code before the sixth birthday and then adult critical care coding rules for the day of the sixth birthday and later. The location of critical care services does not matter, only that the patient is critically ill and how old the patient is at the time care is provided.

Unlike adult critical care codes, neonatal and pediatric critical care codes are not time based and cover all care given to that patient within a 24-hour period. Again, the only coding requirements are age and meeting the definition of requiring critical care. (This is identical to the adult definition covered in an earlier Coding Corner.) Daily progress note documentation of time spent at the bedside is not required.
Since time is not a factor in billing neonatal/pediatric critical care, only one practitioner can bill for care each day. Here is an example: a two-month-old patient is admitted with influenza-associated respiratory failure requiring intubation. Later that evening, when a different physician is covering, the patient deteriorates, requiring placement on high-frequency oscillatory ventilation. The second physician cannot bill for the time spent with this patient.

Additionally, if a child is transferred from the NICU to the PICU (or vice versa) within the same institution during the same admission, the new unit cannot utilize a first-day neonatal/pediatric critical care code; a subsequent day code must be used providing the transferring unit did not already bill for the patient that day. A transfer to another institution or a transfer from a general medical floor can result in a new first-day charge being used.

The other major difference between neonatal/pediatric critical care billing codes and adult critical care billing codes is the inclusion (“bundling”) of many more invasive procedures. In addition to those procedures bundled into the adult critical care billing code, pediatric/neonatal billing codes include the following:

• Arterial catheterization (CPT 36140, 36620)
• Umbilical venous and arterial catheterization (CPT 36510, 36660)
• Central vessel catheterization (CPT 36555)
• Venipuncture, including scalp sites (CPT 36400, 36405, 36406)
• Endotracheal intubation (CPT 31500)
• Surfactant administration (CPT 94610)
• Continuous positive airway pressure (CPAP) and ventilator management (CPT 94660, 94002-94004)
• Transfusion of blood products (CPT 36430, 36440)
• Suprapubic bladder aspiration and bladder catheterization (CPT 51100, 51701, 51702)
• Lumbar puncture (CPT 62270)

Performance of any procedures not listed above can be billed for separately, utilizing the appropriate code modifiers. Notable examples are: chest tube placement/thoracentesis (CPT 32551, 32421), cardiopulmonary resuscitation (CPT 92950), extracorporeal membrane oxygenation (CPT 33946, 33947, 33948, 33949), paracentesis (CPT 49082, 49083), cardioversion/defibrillation (CPT 92960), exchange transfusion (CPT 36455), peripherally inserted central line placement (PICC) < 5 years (CPT 36568).
The fact that neonatal/pediatric critical care billing codes are only used once each 24 hours and include a larger number of procedures affords them higher relative-value units and higher reimbursement value.
Other important billing codes that can be used when caring for a newborn include:

• 99464: Attendance at delivery when requested along with initial stabilization of newborn , OR
• 99465: Attendance at delivery along with provision of positive-pressure ventilation and/or chest compressions

The neonatal critical care code can then also be used in conjunction with the above codes. 

A neonate (0-28 days) who requires intensive care (defined as intensive observation and frequent interventions but not critical care) can utilize the following billing codes:

• 99477:  Initial hospital care, 28 days and younger, all weights
• 99478:  Subsequent intensive care, present weight < 1,500 grams
• 99479:  Subsequent intensive care, present weight, 1,500-2,500 grams
• 99480:  Subsequent intensive care, present weight > 2,500 grams

Billing for neonatal/pediatric critical care is often more straightforward than for adult critical care services. However, knowledge of the specific coding details will result in more thorough and compliant billing.