Pediatric Coding Alert

There are four main ways the extensive new language in CPT 2000 regarding critical care services (99291, 99292) and neonatal intensive care (99295, 99296, 99297, 99298) affects pediatricians.

1. Fewer restrictions on critical care codes. In CPT 1999, critical care services were reserved for the unstable critically ill or unstable critically injured patient who requires constant physician attendance. These services were to be provided to but not limited to patients with central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic or respiratory failure, postoperative complications, or overwhelming infection.

By contrast, CPT 2000 says that critical care services are for the direct delivery by a physician(s) of medical care for a critically ill or injured patient. The introduction goes on to define critical as a condition that acutely impairs one or more vital organ systems such that the patients survival is jeopardized.

The services include but are not limited to the treatment or prevention or further deterioration of central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, or overwhelming infection. The requirement that the patient be unstable no longer appears.

This is a major change, liberalizing the definition of critical care services, says Charles Schulte III, MD, FAAP, the American Academy of Pediatrics representative on the AMAs CPT Coding Committee. Before, the child had to be on a ventilator, he says. Now, the problem can be something other than cardiorespiratory. Pediatricians will be using the critical care codes much more under CPT 2000, says Schulte, who practices with Countryside Pediatrics in Sterling, VA.

Peter Rappo, MD, FAAP, assistant clinical professor of pediatrics at Harvard University, agrees that the critical care services codes are less restrictive. They dont have to be near death all the time, he says. Before, a critical care case was like an episode of ER.

So if you havent used critical care codes much before, its now time to look into how to use them. They pay well and they give you a way to bill for time spent caring for a critically ill patient. More general pediatricians will be using these critical care codes now, says Joel Bradley, Jr., MD, FAAP, editor of the American Academy of Pediatrics Coding for Pediatrics and in practice in Clarksville, TN. (Because there is now potential that the usage of such codes will go up, the RVUs may be reduced, says Bradley, but these codes will still pay well.)

2. Time spent talking to family. Another major change in the critical care services definitionand one that will affect pediatricians significantlyis that time spent talking to the family when on the floor or unit when the patient is unable or clinically incompetent to participate in discussions can be counted as critical
care services.

While it was always clear that the physician did not have to be constantly at the bedside in order to bill critical care services, there was never any language specifically stating that time spent talking to the family could be charged as critical care. In addition, the new definition says that time spent on the unitat the nursing station reviewing test results, discussing the patients care with other staff, and actually documenting critical care services in the recordcan all be billed as critical care services. Note that you cannot bill time spent off the unit or floor, even if discussing the patient with the family, as critical care services.

3. Age. The critical care services definition has been rewritten to specify that these codes should be used for infants who are admitted to an intensive care unit when they are older than one month of age. The neonatal intensive care codes are for neonates who are 30 days of age or less at the time of admission.

To help clarify that pediatricians should be using the critical care services codes for infants who qualify for critical care but are older than 30 days when admitted, CPT 2000 adds the pediatric intensive care unit as a place of service.

4. Time. Finally, the time to be spent on the first critical care code (99291) has been revised. Instead of saying first hour, this code is for the first 30-74 minutes of critical care services. If you provide critical care services of less than 30 minutes, you should use the appropriate E/M services code, as before.

The second code (99292) is to be used for each additional 30 minutes beyond the first 74 minutes. It is also to be used for the final 15-30 minutes of care on a given date. As Bradley says, pediatricians are going
to have to keep close watch on their time when using these codes.