Pediatric Coding Alert

Surprise: Codes 99291, +99292 apply to infants, young pediatric patients in these situations.

Youve got to expand your 99291 and +99292 use, or youll join other practices wasting money appealing legit per diem critical care denials.

Currently, we are being denied [on claims for 99468, Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less] and having to send records and request a review & which is very time-consuming and costly, reports Tommie Angel, practice manager at Sanford Pediatrics PA in North Carolina.

Strategy: Consider additional factors such as setting and time, before choosing 99291, +99292 (Critical Care Services: Adult [Over 24 Months of Age]) or 99466-99476 (Neonatal and Pediatric Critical Care Services).Check out these instances when 99291, +99292 are the right choice for infants and young pediatric patients.

Myth 1: 99291, 99292+ Are for 25 Months and Older

Reality: In three cases, you can apply Critical Care Services for patients less than 25 months of age. Looking at an E/M table or one CPT directive can mislead you into pigeonholing 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]) as adult-only codes.

Table 1 of the E/M services guidelines in CPT 2009 lists 99291-+99292s category/ subcategory as Critical Care Services: Adult [Over 24 Months of Age]. The directive describes the most common use of the codes and is not a restriction.

CPTs Critical Care Services guidelines indicate you should report 99291 and +99292 for the physicians attendance during the transport of a critically ill or critically injured patient over 24 months of age to or from a facility or hospital. This instruction, however, does not mean codes 99291 and +99292 apply only to older patients.

The instruction, which the AMA added to CPT 2009, separates 99291 and +99292 from pediatric transport codes. For physician transport services of critically ill or critically injured pediatric patients, see 99466, 99467.

Myth 2: Age Alone Determines Critical Care Code

CPT 2009s pediatric critical care services expansion might have caused you to focus solely on a patients age when choosing the appropriate critical care code. This one-factor approach, however, can land you with the wrong service category.

Reality: Youve got to look at the setting in which the critical care occurs. The hourly critical care codes are also for critical care that occurs in outpatient offices and in observation status at any age, says Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville.

Myth 3: Length of Stay Doesnt Affect 99468-99476

Reality: The global neonatal and pediatric critical care codes (99468-99476) are for full-day inpatient services. So if your physician is providing the initial partial-day critical care, you should end up with 99291 and possibly also +99292 provided the receiving physician is in a different group.

Example: We have billed the critical care hours for babies we have had to transfer out to a facility where we do not provide the neonatal services, explains Deborah Rushing, CPC, operations manager, Fairfax Neonatal Associates PC in Virginia. The 2009 Inpatient Neonatal and Pediatric Critical Care guidelines state that When critical care services are provided to neonates or pediatric patients less than 5 years of age at two separate institutions by a physician from a different group on the same date of service, the physician from the referring institution should report their critical care services with the critical care codes (99291, +99292) and the receiving institution should report the appropriate global admission code (99468, 99471, 99475, 99476) for the same date of service.

Heres how the above instructions apply when the sending and receiving physicians are in different groups.

The sending physician who provides hourly critical care before transferring the patient to the tertiary facility, uses time-based hourly critical care codes (99291 and possibly +99292). The tertiary facility receiving physician who provides initial inpatient critical care to the neonate for the remainder of the day, reports the global critical care code (such as 99468).

If the groups use the same billing number, then only the per diem critical care code can be used, says Gilbert I. Martin, MD, FAAP, neonatal intensive care unit (NICU) director at Citrus Valley Medical Center in West Covina, Cal. However, if the neo goes on the transport, then 99466 (Critical care services delivered by a physician, face-to-face, during an interfacility transport of a critically ill or critically injured pediatric patient, 24 months of age or less; first 30-74 minutes of hands-on care during transport) and 99467 (& each additional 30 minutes [List separately in addition to code for primary service]) can also be added.

Myth 4: Hourly CC Takes Over After 5th Birthday

Reality: You go from per diem neonatal critical care  codes (99468, 99469, Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less) to pediatric critical care codes (99471, 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; 99472, Subsequent &) at 29 days of age. Use older pediatric patient critical care codes (99475, Initial 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; 99476, Subsequent &) starting at 2 years. Switch to hourly critical care (CC, 99291, +99292) at age 6. CPT 2009 reformatted the ages so that you move from pediatric critical care to hourly CC services after age 5 instead of after 24 months. This reformatting nicely completed the global critical care codes for ages 2-5, Tuck says.

If a physician is taking care of a critically ill pediatric inpatient age 2 through 5, you would use 99475 or 99476 for each days per diem care. 99475 is for initial inpatient pediatric critical care, per day; and 99476 is for subsequent inpatient critical care, per day. On the childs 6th birthday, if he remains in critical care, you would switch from 99476 to hourly critical care codes: 99291, and possibly +99292.