Critical care requires a provider to make highly complex medical decisions for patients who are critically ill or have suffered a critical injury such as multiple traumas. Both critical care illness/injury and critical care treatment criteria must be met, in addition to the age and/or time requirement, to bill critical care services. Critical care is divided into separate categories by age: child to adult (ages 6 and older), pediatric (29 days-24 months of age, 2- 5 years old), and neonate (28 days of age or younger).
- 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).
- 99468 Initial inpatient neonatal critical care, per day, for the Evaluation and Management of a critically ill neonate, 28 days of age or younger.
- 99469 Subsequent inpatient neonatal critical care, per day, for the Evaluation and Management of a critically ill infant or young child, 29 days through 24 months.
- 99471 Initial 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.
- 99472 Subsequent inpatient neonatal critical care, per day, for the Evaluation and Management of a critically ill infant or young child, 29 days through 24 months.
- 99475 Initial inpatient pediatric critical care, per day, for the Evaluation and Management of a critically ill infant or young child, 2 through 5 years of age.
- 99476 Subsequent inpatient pediatric critical care, per day, for the Evaluation and Management of a critically ill infant or young child, 2 through 5 years of age.
Neonates have an additional category of codes for intensive care monitoring. The intensive care codes are for frequent monitoring and interventions for a neonate that does not meet critical care definition but requires intensive observation. This category of code is broken down by the birth weight for all subsequent days of care.
- 99477 Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger.
- 99478 Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present body weight less than 1500 grams).
- 99479 Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present body weight less than 1500-2500 grams).
- 99480 Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present body weight less than 2501-5000 grams).
Have you ever thought, “wouldn’t it be great if they made these intensive care codes for children and adults?” Well, you are not alone. We see patients that are transferred to the PICU or ICU post-operatively for intensive monitoring and observation that do not meet critical care criteria. Providers are left with coding regular subsequent hospital care codes 99231-99233 in the inpatient setting. Do these subsequent hospital care codes really give enough credit to the provider in this scenario?
During my post review education session with provider(s), I talk to them about all services they are providing and all activities that go into frequently monitoring these patients. One option we discuss is the time it takes to manage these patients. There may be another option than just assigning a subsequent hospital visit. Let us investigate the prolonged service codes.
- +99356 Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service; first hour (list separately in addition to code for inpatient or observation Evaluation and Management service)
- +99357 each additional 30 minutes (List separately in addition to code for prolonged services)
If a provider documents 70 minutes of intermittent neuro checks or time spent on the unit/floor, on a post op patient who is 6 years of age or older, we can code based on time with codes 99233 and 99356.
TIP: Make sure you capture all reportable services performed. If an emergent endotracheal intubation is required/performed as part of the pre-admission delivery care for a neonate, code 31500 can be billed in addition to your critical care service. Intubating for convenience before an admission to the neonatal intensive care unit would not be separately reported.
As critical care services have a minimum time requirement, teach your providers to capture and clearly document time spent on other billable procedures. Remember, if you bill for the time spent performing a procedure it should not be calculated in the total critical care time.
For more information, please contact Lori Carlin at LCarlin@AskPHC.com or 206-399-7792.
