Pediatric Coding Alert

New edition of CPT will impact the way you report these pediatric services.

If coding critical care transfers and adjustments have you confused, CPT 2013 has just the cure. The new edition of the manual includes introductory notes that spell out how you should code these services going forward.

Last month, we told you about the new vaccine, pediatric transport, and online evaluation coding changes that will be taking place in 2013, and now we've got the scoop on several other issues heading your way on Jan. 1. Prepare your coding systems now for these updates.

Quell Critical Care Confusion

CPT has updated the introductory language before the neonatal/pediatric critical care codes to clarify which physician should report which service when treating these special needs patients.

According to CPT 2013, neonatal critical care code 99468 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger) should be reported by a single individual physician, per hospital stay, in a given facility. If the patient is released and readmitted, report 99469 (Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger) for the first day of readmission rather than re-reporting 99468.

The initial day neonatal critical care code 99468 can be reported in addition to 99464 (Delivery attendance) or 99465 (Resuscitation) if the physician is present for the delivery or resuscitation.

Know How to Handle Transfers

In cases when a patient is transferred from one institution to another for critical care, the referring physician will use time-based critical care codes (99291,99292) and the receiving physician will report initial day critical care codes (99468, 99471, 99475) if the child is younger than six years of age.

If the patient stays in the same hospital but is transferred to a lower level of care by a different physician in another group, the transferring physician does not report per-day critical care. Instead, he will report subsequent hospital care (99231-99233) or time-based critical care (99291-99292). The receiving physician reports subsequent intensive care (99478-99480) or hospital care (99231-99233). If the patient improves and is transferred to another physician in the same group, both should report subsequent hospital care (99231-99233) or subsequent newborn care (99462).

If the neonate or infant becomes critically ill on a day when the physician performs intensive care services, hospital, or normal newborn services and then the patient is transferred to critical care by a different physician in a different group, the transferring physician reports either time-based critical care (99291-99292), intensive care (99477-99480), hospital care (99221-99233), or normal newborn service (99460, 99461, 99462) " but only one of these. The receiving doctor reports initial or subsequent critical care (99468-99476) based on the patient's age and facility location.

Double visits: If a newborn becomes critically ill on the same day he has already received normal newborn care (99460, 99461, 99462) and the same physician or group assumes critical care, you should report initial critical care services (99468) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended, in addition to reporting the normal newborn code.

Intensive Care Services Differ Slightly

As you are probably aware, critical care differs from intensive care, and the coding rules also differ. In cases when a neonate becomes critical after having been seen as intensive on the same day and is being treated in critical care by a physician in a different group, you'll code this way: The transferring physician reports time-based critical care (99291-99292), intensive care (99477-99480), hospital care (99221-99233), or normal newborn service (99460-99462), but only one service, CPT 2013 indicates.

The receiving physician reports initial or subsequent critical care (99468-99476) based on the patient's age. If, however, the neonate becomes critical after same-day care and is treated by a physician from the same group, you'll report either intensive care or critical care, but not both, CPT explains.

CPT 2013 also clarifies a long-standing difficult coding scenario. Currently, CPT instructs you to append modifier 52 (Reduced services) if you perform less than seven hours of pediatric sleep testing. However, thanks to the addition of the following codes, those rules have changed:

• 95808 (Revised): Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist
• 95810 (Revised): ...age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
• 95811 (Revised): ...age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist
• 95782 (New code)...younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist
• 95783 (New code) ...younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist

Under the new rules, effective on Jan. 1, you'll append modifier 52 if less than six hours of recording take place for 95800, 95801, 95806, 95807, and 95810-95811.

Likewise, if less than seven hours of recording take place for 95782-95783 or if fewer than four nap opportunities are recorded for 95805, you'll append modifier 52.