Pediatric Coding Alert

Question: A child less than five months old was admitted into the ICU, then our pediatrician watched the child acutely for an hour before the patient was transferred to another facility where another provider assumed care. Which CPT® codes can our practice bill? Would the critical care (99291) code be billed for one hour? If so, then we could also select an admit code?

Answer: Hourly critical care codes are the appropriate codes for the transferring physician to bill in this scenario, regardless of the age of the child. 

The critical care requirements, including the constant attention required for organ system failure or progression of organ system failure, must be met. Keep in mind that at least 30 minutes of critical care must be provided before the first hour of critical care can be billed. Otherwise, the billing is all based on E/M codes.

The issue of billing a separate admission E/M code in this scenario must be carefully evaluated and addressed. The E/M service must be separately provided and documented, with no double dipping of critical care and E/M work or time. If the child just received critical care from the moment she was admitted, then all would be billed as time-based critical care. However, typically an admission E/M service is provided and billed in addition to the separate critical care time. 

There are also well-defined procedures that are included in the critical care codes. These services should also not be separately billed, and again would count as double-dipping. These include blood draws, chest x-rays, and other services.

As always, meticulous documentation is necessary, including careful documentation of the time spent with the patient in critical care.