Pediatric Coding Alert

You conquered neonatal-to-pediatric transitional coding, but one great divide remains: finishing the terrible twos.

Although CPT made the initial shift from "neonatal" to "pediatric" critical care quite clear, some ambiguity remains regarding how you should code a pediatric patient who remains critically ill past 24 months of age, says Joel F. Bradley Jr., MD, FAAP, a pediatrician for Premier Medical Group in Clarksville, Tenn.

He's an Adult at 24+

Similar to the first great divide from neonate to pediatric, the age change from two years to two years and a day requires shifting between CPT subsections. When a pediatric patient reaches 24 months plus one day of age, you should no longer report pediatric critical care codes (99293, Initial 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; and 99294, Subsequent 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), Bradley says. "You should instead start reporting the hourly critical care codes (99291-99292), which may be used for adults and older children, once the critically ill patient is over 24 months of age."

The Revisions Never End

To emphasize that you should switch from the pediatric critical care codes to the adult critical care codes, the American Academy of Pediatrics (AAP) requested a revision to the codes for 2004. The AAP suggested that CPT update the neonatal and pediatric critical care services guidelines to "the critically ill or critically injured child older than 24 months of age would be reported with hourly critical care service codes (99291-99292)." The alteration would replace "two years" with "24 months," eliminating the confusion the general term "older than two years" causes (see page 21, CPT Professional Edition , middle of third paragraph), Bradley says. In addition, the language would remove the location from the description, which now reads "when admitted to an intensive care unit."

The critical care codes are not location-specific. CPT does not require a neonate to be in a neonatal intensive care unit (NICU) or a pediatric to be in a pediatric intensive care unit (PICU) to report these codes. The patient's status as critically ill determines the code, not his or her physical location, says Richard A. Molteni, MD, FAAP, vice president of Children's Hospital & Regional Medical Center in Seattle.

Transition From Pediatric to Adult

Location is not crucial to the critical care codes because hospitals may provide treatment in various departments based on their facilities. A rural hospital in Florida, for instance, may not have a PICU and provides all critical care in the same unit. You should still report the code based on the patient's age and status.

For example, a boy who is 23 months 3.5 weeks old is injured in a car accident and receives critical care services in a hospital's critical care unit. A pediatrician provides initial care on the day of admission and subsequent care for three days. The child turns 24 months plus one day old on day 3 of his hospital stay.

You should assign the pediatric care codes per day until the boy turns 24 months and one day old. For the admission day, you should report initial pediatric critical care (99293), plus any procedures not included in the 24-hour global pediatric critical care code (very few!). For the pediatrician's critical care services on day 2, use subsequent pediatric critical care (99294). You should use 99293 and 99294, regardless of where the pediatrician provides care, as long as the child meets CPT's criteria of a critically ill patient.

Remember to shift codes when the patient is beyond 24 months of age. When he is over 24 months old on day 3, in this example, you should start reporting the hourly critical care codes (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]), Bradley says. Procedures not included in the critical care codes would also be billed. Do not include time spent doing these procedures in the critical care time. Combine the pediatrician's total time spent with the patient on each day to arrive at the correct code set. If the physician, in this scenario, spends one and a half hours on day 3 and one hour on day 4 providing critical care services, report 99291 x 1 plus 99292 x 1 (day 3) and 99291 x 1 (day 4), respectively. Additional E/M coding, such as 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ... physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit), for each day (3-4) would also be appropriate for noncritical care services on those days.