Pediatric Coding Alert

Question: After an 11-year-old patient went to the emergency department (ED), our pediatrician admitted him to the pediatric intensive care unit (PICU). What E/M code should I use for the admit to the PICU?

The patient has type I diabetes and was admitted for vomiting and moderate-to-large ketones. He was given fluids and an insulin drip in the ED -- that's all that is documented. The pediatrician did not document time spent with the patient, who was awake and alert during the exam in the ED.


South Dakota Subscriber

Answer: Report the admission with initial hospital care codes 99221-CPT 99223 (Initial hospital care, per day, for the evaluation and management of a patient ...).

Why: Daily critical care codes exist for newborns (99295-99296, inpatient neonatal critical care) and children through 24 months of age (99293-99294, inpatient pediatric critical care). Therefore when a pediatrician provides daily inpatient care to a patient 2 years of age and older, you should code the appropriate hospital care (such as 99221-99223 or 99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...) and any applicable critical care time (99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes; +99292, ... each additional 30 minutes [list separately in addition to code for primary service]).

Codes 99291-99292 are time-based, so the pediatrician must document the time spent providing critical care services to a critically ill or critically injured patient.

Problem: Coding should be based on the level of care required, not the site of service. The documentation that you mention does not describe critical care services or critical care time. Because the location (PICU) alone does not warrant coding critical care services and the patient does not meet the criteria for per-day pediatric critical care, you should instead report the appropriate level of initial hospital care (99221-99223).