ED Coding and Reimbursement Alert

Question: Our ED physician saw a critically ill pediatric patient yesterday but has never treated a child for CC services before. How do the pediatric critical care coding rules differ from the adult patient rules?

Codify Subscriber

Answer: When you’re reporting critical care services for pediatric patients, in the ED setting, you would still use 99291 and 99292 if it is also indicated. There are pediatric critical care codes, 99468 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger) through 99476 (Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age), but those are only for use in an inpatient neonatal or pediatric critical care unit and not in the ED. Because the codes describe the whole calendar day rather than just the first hour of critical care, the assigned RVUs are significantly higher. A physician covering the ED should not also be covering the inpatient pediatric unit on the same day.

Even if the emergency physician was responding to a crisis on an inpatient pediatric critical care unit (PICU), you would likely report the services with 99291-99292 (assuming the appropriate criteria were met) rather than the pediatric specific critical care codes since 99471-99472 are intended to represent an entire day of care

Pediatric patients who receive critical care must meet the definition of critically ill or injured, just as an older patient would. The criteria that the patient has to be critically ill or injured such that there is a threat to life and limb applies to all of the critical care codes.