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Revisiting Neonatal and Pediatric Critical Care Services

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Neonatal and pediatric critical care coding guidelines have been modified over the years, but the definitions remain the same. The patient must meet the same clinical criteria as for the adult critical care codes 99291 and 99292. Critical care can be provided by a physician(s) or other qualified healthcare professional(s) of medical care for critically ill or injured patients.

According to CPT, “A critical illness or injury 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. Critical care involves 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.”1

The neonatal and pediatric critical care codes are not time based but rather are reported per calendar day for the evaluation and management of a neonatal or pediatric patient. The codes are selected based on:

  • Initial visit and subsequent days
  • Age and/or birth weight (for neonates)
These codes can be reported only in the inpatient setting. These codes are not used for critical care that is delivered in the emergency department or outpatient setting. Instead, CPT codes 99291 and 99292 are used, based on time. Sometimes the physician starts critical care management in the outpatient setting and admits the neonatal or pediatric patient to the hospital. How should these service be reported? The physician would report the neonatal or pediatric critical care codes for the encounter, not 99291 or 99292.

Often, more than one physician or advanced practice provider from different specialties manage a critical care patient. For example, if a cardiologist and a pulmonologist are both managing a patient for different conditions and both conditions meet the definition of critical care, one physician reports the neonatal or pediatric critical care codes and the other reports 99291 or 99292, based on time. In 2018, CPT amended the guidelines to allow for different specialties within the same group to provide critical care services to neonatal and pediatric patients.

Initial-day critical care codes are reported only once during an admission for a patient younger than age 6 years. If the patient still requires critical care on the 29th day of life during the same hospital stay, the pediatric subsequent critical care code 99472 is reported.

Modifier 63 should be reported for procedures performed on neonates or infants up to a body weight of 4 kg (8.8 lbs) that may involve significant increased complexity and physician work. Documentation must support the complexity of the patient’s care.

What if a neonate is first treated at one hospital and then transferred to another? CPT guidelines direct the transferring hospital to report the time based critical care codes 99291 or 99292 and the receiving hospital to report the per diem neonatal or pediatric codes.

Neonatal Critical Care Codes

Pediatric Critical Care Codes
CPT codes 99471 and 99472 are for management of a critical care patient aged 29 days through 24 months. CPT code 99471 is for the initial inpatient encounter. CPT code 99472 is for subsequent days. Again, these are reported only once per calendar day

CPT codes 99475 and 99476 are reported for patients aged 2 through 5 years. If the patient still requires critical care and has reached his/her 2nd birthday, 99476 is reported. On the patient’s 6th birthday, 99291 or 99292 are used from then on.

When more than one specialty is managing the critical care portion of the patient’s care, the primary physician reports 99471-2 or 99475-6 and the specialists report 99291 or 99292 based on time per day.

Intensive Care Services
Intensive care services codes 99477-99480 are used for management of low-birth-weight and recovering infants. These patients may not require critical care but do require intensive monitoring, frequent interventions, and other intensive care services. These codes are not based on what unit the patients are located in. Care can be provided in any area of the inpatient hospital setting. Make sure your documentation supports medical necessity for the intensive monitoring.

Other Services
Codes associated with delivery room care of critically ill neonates, standby services, attendance to infants during labor and delivery, newborn resuscitation, and other necessary services can be reported in addition to codes 99464 and 99465. Codes 99466 and 99467are reported for critical care transport services for patients aged 24 months and younger. Critical care transport of less than 30 minutes’ duration should be reported with the appropriate E/M code.

Physician-directed emergency care via phone to transporting personnel is reported with code 99288. Physician supervision of the interfacility transfer of a critically ill child aged 2 years or younger by a specialized transport team is reported with codes 99485 and 99486. Only actual time spent in two-way communication with the team is reported. Keep in mind that times of less than 15 minutes should not be reported. As with all time-based services, total duration of time should be clearly documented.

CPT Codes
Bundled Into Neonatal and Pediatric Critical Care The following CPT codes are included in the pediatric critical care codes and are not reported separately. As with older patients, cardiopulmonary resuscitation, peripherally inserted central catheter insertion, intraosseous line insertion, hemofiltration catheter placement, thoracentesis, pericardiocentesis, extracorporeal membrane oxygenation management, as well as other services are not bundled.

Make sure that documentation supports critical care services for the neonatal or pediatric patient and that the correct CPT codes are reported.

American Medical Association. CPT Professional. Chicago, IL; American Medical Association; 2019.
American Medical Association. CPT Assistant. Vol 28. Issue 6. Chicago, IL; American Medical Association; 2018.
American Medical Association. CPT Assistant. Vol 26. Issue 5. Chicago, IL; American Medical Association; 2016.
U.S. Centers for Medicare and Medicaid Services. CMS-1693-F. Revisions to Payment Policies under the Medicare Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B for CY 2019. CY2019-PFS-FR-Addenda B. https://go.cms. gov/2ImRbQv. Accessed February 21, 2019.

1. American Medical Association. CPT Professional. Chicago, IL; American Medical Association; 2019.