Pediatric Coding Alert

Question: When a critically ill infant remains critical past 30 days of life, do we have to change to the pediatric intensive care unit (PICU) codes on day 31, or do the neonatal intensive care unit (NICU) codes apply as long as the baby never leaves the hospital during his stay (the definition for 2002 codes)? If the PICU codes start on day 31, should we report 99293 for day 31 and switch to 99294 as long as the baby meets the criteria, or should we go to 99294 on day 31?

Connecticut Subscriber

Answer: You should follow the age restrictions in the neonatal and pediatric critical care codes' descriptions. Neonatal critical care codes 99295 (Initial neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 30 days of age or less) and 99296 (Subsequent neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 30 days of age or less) are for neonates, 30 days of age or less.

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) are for infants or young children, age 31 days to 24 months.

Do not get bogged down in details, such as location. Although the hospital may not have a separate NICU and PICU, so no room transfer occurs, you should still switch codes as the neonate becomes an infant. Of course, as you mention, the patient must meet critically ill criteria for you to bill 99293-99296.

Remember that these codes also specify initial and subsequent care. Think of "initial" and "subsequent" in general terms, rather than location specific. The pediatrician provides initial and subsequent care, not initial neonatal care and subsequent pediatric care. If the doctor has not provided care to the individual during the current hospital stay, the physician is providing initial care. If he has already started to care for the patient, the pediatrician is performing subsequent care.

For instance, a pediatrician admits a critically ill neonate who is 27 days of age to the NICU. The neonate remains critical for five additional days until 32 days of age. On the sixth day (age 33 days), the pediatrician transfers the infant to an intensive care setting where he remains for day 7. The doctor spends an hour discharging the patient on the eighth day (age 35 days). To solve the scenario, follow this chart:

For the neonate's admission at 27 days of age to critical care, report 99295. For the subsequent care until the neonate becomes 31 days of age, assign 99294 per day (a total of three days). While the infant remains critical from 31-32 days of age, use 99296 per day (a total of two days). Although the patient is now an infant, the pediatrician is still providing subsequent care.

When the infant is no longer critical from 33-34 days of age, report the subsequent hospital care code (9923x) per day (a total of two days). On the discharge day, use 99239 (Hospital discharge day management; more than 30 minutes). Coding for the complete hospital stay is: