ED Coding and Reimbursement Alert

Question: The ambulance brings an unconscious 1-year-old child to the ED. The mother reports that she went to check on the child while he was sleeping, and found him unresponsive. After performing CPR, the ED physician performs 45 minutes of critical care, during which time he takes chest X-rays and performs pulse oximetry. How do I report this encounter?

Connecticut Subscriber

Answer: First, let's address what you should not report. Do not make the mistake of coding 99293 (Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age) for the critical care, even though the child was only a year old.

Why? Since CPT's pediatric critical care codes are not time-based, the physician typically needs to perform a full day of service to report 99293 or 99295 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less). Inpatient critical care wards use these codes frequently, but you should not use them in the ED.

Coding: You should instead rely on standard critical care codes in the ED -- even for children and infants. On the claim, report the following:

- 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the critical care

- 92950 (Cardiopulmonary resuscitation [e.g., in cardiac arrest]) for the CPR.

You should not code separately for the X-rays or oximetry, as those services are bundled into 99291.

Remember: The critical care time must be counted separately from the time the physician spent performing CPR. So if the ED physician spent 12 minutes performing CPR, be sure to carve that time out of the total critical care minutes.