Pediatric Coding Alert

Question: Our pediatrician is trying to report a standard hospital care code, whereas we think he qualifies for a critical care code. He argues that the patient was in the emergency room and not the critical care unit when he treated her. Can you advise? 

Answer: Whether the patient was critically ill or injured is the most important question you’ll need to answer on any critical care claim. You must be able to establish that the patient is critically ill or injured to report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) or +99292 (… each additional 30 minutes [List separately in addition to code for primary service]).

CPT® defines critically ill or injured as “an injury or illness that acutely impairs one or more vital organ systems such that there is high probability of imminent or life threatening deterioration in the patient’s condition.” In addition, minimal time thresholds of care, at least 30 minutes must be clear from the medical records.

The following examples describe patients that insurers would typically consider critically ill or injured:

• An acute asthma exacerbation patient requiring multiple nebulizer treatments and close monitoring with perhaps the use of third line agents such as magnesium;
• A motor vehicle accident victim with concerning internal injuries, altered mental status or significant fractures; and
• Unstable vital signs, severe hypernatremia, severe dyspnea, or a hypertensive crisis.

Although most critical patients will be actively critically ill or injured, some may just be unstable to the point that they will very likely become so without immediate treatment.

When determining whether or not a patient is critically ill or injured, the physician should consider the likelihood that they would have a clinically significant deterioration if nothing was done in the next hour. If the probability for imminent or life threatening deterioration is high, critical care may be an appropriate consideration. For example, consider a patient with an allergic reaction with severe laryngeal swelling that threatens to close off his airway, but is not yet fully decompensated and requiring intubation.

As for the emergency room versus the critical care unit, place of service is not restricted in CPT® other than to identify typical areas of a facility where it may occur. While most critical care will occur in a critical care area (such as the pediatric intensive care unit or the neonatal intensive care unit), the physician can provide 99291 services in any place of service the patient requiring it presents, even in your office.