Pediatric Coding Alert

Experts reveal how 5 revamped instructions will simplify your 99289-99296 options

If critical care codes confuse you, you'll welcome CPT Codes 2004's new guidelines that clarify some of your major neonatal and pediatric coding dilemmas.
 
CPT 2003's introduction of neonatal and pediatric critical care services left some billing ambiguities, such as how you should report in-office critical care, in-office critical care that results in a transfer of care or inpatient hospitalization, and interfacility transports of patients more than 2 years of age. You may also not have known how to code for a critically ill child who remains critically ill past 24 months of age or for delivery-room procedures that your pediatrician provides before initial neonatal critical care. To solve your challenges, the AMA revised the critical care guidelines to ease pediatric coding.
 
Starting Jan. 1, 2004, coding experts recommend that you bill for critical care services based on the following five guidelines.

1. For Outpatient Critical Care, Assign 99291-99292

The biggest pediatric change for 2004 specifies that you should assign 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 services, says Richard Molteni, MD, FAAP, a neonatologist and vice president of Children's Hospital & Regional Medical Center in Seattle. "The patient's age no longer matters."
 
You may report 99291-99292 in the following locations: the office (place-of-service code 11), urgent care facility (POS 20), pediatric outpatient floor (POS 22, outpatient hospital), hospital emergency room (POS 23) and ambulance (POS 41, land; POS 42, air or water), says David G. Jamiovich, MD, transportation code creator and pediatric transport program medical director at Hope Children's Hospital in Oak Lawn, Ill. But don't use 99291-99292 in the delivery room, which is part of inpatient hospital care (POS 21).

2. Reserve 99293-99296 for Inpatient Critical Care

If you struggle with coding for outpatient critical care services that result in transfers of care, CPT's critical care revision simplifies your options, Jamiovich says. When your pediatrician provides outpatient critical care services before sending the patient to a specialist for inpatient services, you should report 99291-99292, he says. The specialist, such as a neonatologist, would then report the codes for global 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; 99296, Subsequent 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; 99294, Subsequent 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).
 
For instance, a mother presents to a pediatrician's office with her 6-month-old son, who has diarrhea (787.91) and dehydration (276.5). While the mother is waiting for her appointment, the infant goes into hypovolemic shock (785.59). The pediatrician provides one hour of in-office critical care prior to a transport team arriving to transfer the infant to an intensive care unit. For the outpatient critical care, you should report 99291. The receiving physician will assign the 24-hour global initial inpatient pediatric care (99293).
 
But if the pediatrician also provides the inpatient critical care, you shouldn't report the outpatient services. Instead, you should roll the outpatient E/M (99291) into the inpatient service (99293), CPT states.

3. Use 99291-99292 for 'Adult' Interfacility Transport

The revised critical care guidelines answer a common pediatric question: Which code should you use for interfacility transports of children more than 2 years of age? "As long as your pediatrician accompanies the child in the
transport vehicle, CPT 2004 specifies that you should use 99291-99292," Jamiovich says.
 
For patients who are 24 months of age or younger, you should use codes for pediatric critical care patient transport (99289, Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or less; first 30-74 minutes of hands-on care during transport; +99290, ... each additional 30 minutes ...).

4. Switch to Hourly Critical Care After 24 Months

CPT 2004 also clarifies that you should use hourly critical care codes (99291-99292) when a critically ill pediatric patient remains critically ill past 24 months of age, says Joel F. Bradley Jr., MD, FAAP, a pediatrician at Premier Medical Group in Clarksville, Tenn. Although CPT 2003 made the coding shift from neonatal to pediatric critical care codes quite clear, many pediatric coders struggled with coding for a single critical care episode in which a pediatric patient transferred to older than 2 years.
 
But two editorial changes simplify your coding options. First, the revised inpatient neonatal and pediatric critical care services guidelines replace "2 years" with "24 months," eliminating the confusion the general term "older than 2 years" causes, Bradley says. In addition, the language removes the location from the description, which previously read, "when admitted to an intensive care unit."
 
These two changes mean that you should switch to 99291-99292 when a critically ill patient turns 24 months and 1 day of age. For instance, a pediatrician admits a critically ill pediatric patient to inpatient status three days before the child turns 24 months of age. You should use global pediatric critical care codes (99293 on day one and 99294 on days two, three and four) for the first four days of inpatient critical care. When the child turns 24 months and 1 day of age on the fifth inpatient critical care day, you should switch to hourly critical care codes (99291-99292) if the child continues to meet CPT's critical care criteria, Molteni says.

5. Append -59 to Preadmission Revival Procedures

 If, while attending a delivery, your pediatrician has to perform other procedures as a necessary part of a resuscitation, CPT 2004 spells out that the preadmission care is separately reportable. CPT bundles procedures such as endotracheal intubation (31500, Intubation, endotracheal, emergency procedure) and umbilical arterial catheterization (36660, Catheterization, umbilical artery, newborn, for diagnosis or therapy) into global inpatient neonatal critical care codes (99295-99296). But when your pediatrician performs resuscitation-related procedures as part of the pre-admission delivery care, they aren't included in the global codes. To report these procedures separately, the physician must perform them as a necessary component of the resuscitation and not simply as a convenience before admission to the neonatal intensive care unit (NICU), CPT states.
 
You may report medically necessary delivery-room procedures in addition to inpatient critical care services because the care occurs at different sites of service. That's what makes preadmission procedures distinct procedural services from inpatient critical care. To indicate this distinction, you must append modifier -59 (Distinct procedural service) to the delivery-room procedures.
 
For instance, a pediatrician attends a high-risk delivery in which he performs resuscitation with medically necessary endotracheal intubation prior to admitting the neonate to the NICU. You should report newborn resuscitation (99440, Newborn resuscitation: provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output), initial inpatient neonatal critical care (99295), and endotracheal intubation (31500-59). To indicate that the intubation is a distinct procedural service from the inpatient critical care services, you should append modifier -59 to 31500.
 
Using the modifier will also override the National Correct Coding Initiative edits that bundle 31500 into 99295. The edits contain a "1" modifier, which means NCCI permits you to use modifier -59 when appropriate to unbundle the code set.