Gastroenterology Coding Alert

Question: Our gastroenterologist has never done rounds at a children’s hospital, but this weekend there was a pediatric patient in the general hospital where he rounds. How do the pediatric critical care coding rules differ from the adult patient rules?

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Answer: When you’re reporting critical care services for pediatric patients, some of the claims will require 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).

If the patient is six years or older, however, you’ll revert to “adult” critical care codes 99291 (Critical care,  eval­uation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (… each additional 30 minutes [List separately in addition to code for primary service]).

You need to remember, however, that the patient must still meet the parameters for critical care in order to report 99468-99476. The same clinical definition for critical care services apply to the adult, child, and neonate. The variability is the time threshold per age; per day versus per hour.

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.