Pediatric Coding Alert

 Follow these do's and don'ts when you bill hourly critical care codes

Not sure when you should use hourly critical care codes (99291-99292)? Before submitting your 99291-99292 claim, make sure you run through your list of do's and don'ts:

Do report CPT 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]) for all outpatient critical care.

Do bill other E/M codes, such as 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient), with same-day 99291-99292 services when appropriate.

Do switch to hourly critical care codes when a critically ill inpatient turns 24 months of age and 1 day.

Do use 99291 for the first 30-74 minutes of critical care services.

Do bill 99291-99292 when your pediatrician treats a critically ill neonate prior to transferring the infant to a specialist, such as a neonatologist or internist.

Do report 99291-99292 when a pediatrician accompanies interfacility transports of critically ill patients older than 24 months of age.

Do report 99291-99292 when the patient meets CPT's critical care guidelines.

Don't bill 99291-99292 just because the patient is in an intensive care unit.

Don't bill 99291-99292 when your pediatrician provides outpatient (99291-99292) critical care services on the same day as initial inpatient neonatal critical care (99295, Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 30 days of age or less) or pediatric critical care (99293, Initial inpatient pediatric critical care, 31 days up through 24 months of age, per day, for the evaluation and management of a critically ill infant or young child).

Don't charge 99292 as a standalone code. It's an add-on code, so you must always report it in addition to 99291.

Don't assign 99291-99292 for critically ill inpatients 24 months of age and less. Instead, you should use the age-specific neonatal (99295, Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 30 days of age or less; or 99296, Subsequent ...) or pediatric code (99293, Initial inpatient pediatric critical care, 31 days up through 24 months of age, per day, for the evaluation and management of a critically ill infant or young child; or 99294, Subsequent ...).

Don't stop counting hourly critical care time because the pediatrician provides noncontinuous services. Add up the total duration of time the pediatrician spends devoting his or her full attention to the critically ill patient on a given date.

Don't report cardiac output measurements (93561, 93562), chest x-rays (71010, 71015, 71020), pulse oximetry (94760, 94761, 94762), blood gases, and information data stored in computers (such as electrocardiograms [ECGs, blood pressures, hematologic data [99090]), gastric intubation (43752, 91105), temporary transcutaneous pacing (92953), ventilatory management (94656, 94657, 94660, 94662), and vascular access procedures (36000, 36410, 36415, 36540, 36660) in addition to 99291-99292.

Don't use 99291-99292 in the delivery room.