Primary Care Coding Alert

Question: Our hospital physician provided a neonate with critical care throughout the first 28 days of life, and we billed the subsequent visits with the neonate code. But, when the patient turns 29 days old and receives critical care, do I bill that as an initial visit because it’s a new code set, or do I bill as a subsequent visit because the physician has been seeing the patient all along?

AAPC Forum Participant

Answer: Starting on day 29, you’ll bill 99472 (Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age). Here’s why.

Logically speaking, while there is a new code set for infants over the age of 29, the work involved matches that of a subsequent visit not an initial visit. Additionally, the evaluation and management (E/M) Section Guidelines for Inpatient Neonatal and Pediatric Critical Care codes 99468-99476 say the codes “represent care starting with the date of admission for critical care services.”

So, let’s say the patient’s initial visit for critical care was at 20 days old. That would call for code 99468 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger), then 99469 (Subsequent…) for subsequent care up until day 29. As long as the admission was continuous and the patient moved into the next age range of 29 days to 24 months before the end of critical care services, you would bill 99472 for subsequent inpatient critical care services provided to the patient starting at 29 days.