Pediatric Coding Alert

Critical care services (99291, critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes, and 99292, ... each additional 30 minutes) have been redefined in CPT Codes 2001. These codes can now be used only when the child is, indeed, critically ill. The descriptors in the codes themselves have not changed, and neither have the code numbers. But the introductory verbiage in the CPT manual has been substantially altered, with additions that clearly restrict the use of these codes. And HCFA has increased the relative value units (RVU) accordingly: total work RVUs are 5.71 for 99291, and 2.92 for 99292 for 2001, up from 5.09 and 2.51, respectively.

The new language in CPT 2001 includes several elements that are key to understanding when to bill for critical care services. These include:

1. Critical Injury. CPT 2000 defined critical care as the delivery of care for a critically ill or injured patient. CPT 2001 inserts the word critically before injured, so there is no confusion about this: the patient must be critically injured.

2. Life Threatening. CPT 2000 provided that a critical illness or injury impairs one or more organ systems to the extent that the patients survival is jeopardized. CPT 2001 honed this language to state that the organ system impairment must be such that there is a high probability of imminent or life-threatening deterioration in the patients condition. In the introduction, CPT 2001 inserts the phrase life threatening before the word deterioration.

3. Vital Organ System Failure. The examples listed under what could constitute vital organ system failure in the critical care introduction are much more specific in CPT 2001 than in CPT 2000. But, these are just examples and are not definitive. The list itself is similar in 2000 and 2001.

4. Advanced Technologies. CPT 2000 said critical care may require extensive interpretation of multiple databases and the application of advanced technology. On the other hand, CPT 2001 uses the more demanding phrase typically requires:

Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life-threatening situation when these elements are not present.

5. Illness and Treatment. The new descriptor in CPT 2001 clearly states that the patients condition is not the only determining factor when using the critical care codes, but the treatment being provided as well. This is the one worrisome thing about the new verbiage, says Joel Bradley, MD, FAAP, a member of the American Academy of Pediatrics (AAP) coding and reimbursement committee. Some children need a physician at the bedside, but theyre not on a ventilator, maybe not getting any treatment but IV fluids, he says, noting that this may happen after an automobile accident. An adult in a similar situation may be getting 60 medications, but not a child.

6. Other E/M Services. Under CPT 2001, the physician may provide other evaluation and management (E/M) services in addition to critical care on the same date. For example, you may admit a patient to the hospital (99221-99223) in the morning, and later in the day the patient may develop a condition that warrants use of the critical care codes.

7. Time Spent With Family. As in CPT 2000, you can bill critical care codes for time spent discussing treatment with the family when the patient is unable to participate in such discussions. This time must be spent on the floor or unit. A new phrase, however, requires that critical care codes be used only for discussions with the family when the conversation bears directly on the management of the patient. For pediatricians, whose patients are frequently unable to discuss treatment options due to age alone, being able to bill critical care codes for discussions with the family is very helpful. They must make sure, however, that the discussion has to do with the patients treatment.

What the Changes Mean

What does the new critical care language mean for pediatricians? How can you tell if a case merits these codes? These codes are for a patient who is critical, critical, critical, says Charles A. Scott, MD, FAAP, who practices with Medford Pediatric & Adolescent Medicine in Medford, N.J. The child may have been in a motor vehicle accident, in which case the pediatrician would be in the emergency room, probably along with surgeons.

For most general office-based pediatricians, these codes will be used only when the pediatrician is stabilizing a child while waiting for transport to a tertiary care center, Scott notes. Local community hospitals usually are not equipped for critical care, so the pediatricians role is going to be with the child until transport arrives. This usually takes longer than 30 minutes, he says. As a result, the pediatrician would bill both 99291 and 99292.

Note: Not all children who are transported to another facility are critically ill or injured, and therefore staying with a child until transport arrives does not necessarily mean you can bill critical care codes.

Comparing 2000 to 2001

Meningitis is a good example of a condition that may have warranted critical care codes under certain circumstances in 2000. In 2001, those circumstances have become much more dire. In CPT 2000, for example, if a child with meningitis needed constant attention for an hour and the pediatrician needed to begin intravenous antibiotics, you might have been able to bill the critical care codes, says Richard H. Tuck, MD, FAAP, a member of the AAPs coding and reimbursement committee. Now, youre going to need organ system failure, such as respiratory failure (518.81) or septic shock (785.59), to bill these codes.

Under the new critical care codes, determining when a meningitis case becomes critical should be more clear, coding experts say. Sometimes a case becomes critical after a few days. Youve done the workup spinal tap, other tests, started an IV, then, after the second day in the hospital, the child has unrelenting seizures. There is cerebral edema (348.5), the child is very obtunded, you get a CAT scan and consider intubation (31500), Scott says.

Ventilator management could indeed be a measure of critical care. Although it is not required for using critical care codes, one of the measures that would clearly be worthy of critical care services is intubation or ventilator management, Tuck says. Scott agrees: I cant imagine many times when a child would be critical and I wouldnt at least be considering intubation. When you are trying to control a case, you have to think about grabbing hold of the airway and having control over it. Whether the child requires intubation could be an indicator of when you should use the critical care codes.

But Bradley, editor of the current edition of Coding for Pediatrics, published by the AAP, notes that intubation is not a defining measure. A lot of kids are not intubated but would still qualify for critical care codes, he says. Maybe the child has asthma and is having a lot of respiratory effort. The PC02 is rising, the child goes to the critical care unit and gets inhaled bronchodilators constantly over a period of two or three hours, or is on IV medication. This child could still be a critical care case, even though there is no intubation.

Jeff Linzer Sr., MD, FAAP, MICP, director of emergency medicine at Childrens Healthcare of Atlanta, doesnt believe that the critical care codes were really loosened up much in 2000. I think what was critical care in 2000 will still be in 2001, he says. This is particularly true for pediatrics, he says.

Care Location is Irrelevant

Linzer notes that where critical care is provided doesnt matter in an emergency department, in a hospital unit, on the street, or in the office. For example, a child develops anaphylactic syndrome, which rapidly progresses to symptoms of shock. The child requires IV fluids to maintain vital signs, epinephrine and H1 and H2 antihistamines, all to keep from further deteriorating. The child may or may not need ventilator support. This patient would certainly qualify for critical care codes, Linzer says, although he notes that if emergency medical services arrives within 30 minutes, you cannot bill critical care.

Another example of in-office critical care services is a child in hypovolemic shock due to severe gastroenteritis. There are signs of shock, Linzer says. The blood pressure may still be fine thats one of the last things to go but there is elevated heart rate. The child needs IV fluids and monitoring of vital signs. Pressors may be required. This case also merits critical care, Linzer says. This is a very good example of when the adult definition of critical care does not match the pediatric definition. An adult would get many more treatments due to risk factors that children dont have. But the child would still qualify for critical care.

So what do the restrictions in critical care codes really mean for primary care pediatricians? For many, not much, because they billed few critical care services in 2000, and they will do the same in 2001. Scott says the real difference between the CPT 2000 and CPT 2001 definitions of critical care services is that the newer codes are clearly for an ICU-bound patient. Under the 2000 guidelines, the codes could have been used for intensive work, he says. Now, they are only for the critically ill.

Tip: You can bill charting time under the critical care codes, as long as its done on the floor. Although this isnt new for 2001, the amount of charting that you will have to do is. There is a lot more documenting for these codes than there was before, Bradley notes.