Taking the Crisis Out of Pediatric Critical Care Coding

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Taking the Crisis Out of Critical Care Coding

Office of Corporate Compliance

May 2003

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Course Objectives

• Critical Care Criteria

• Discerning Critical Care Codes and Required Documentation

• Modifiers Applicable to Critical Care

• Common Pitfalls

• Bundled Services

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Critical Care Criteria

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CPT Definition“Critical care is the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such as that there is a high probability of imminent or life threatening deterioration in the patient’s condition. Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or prevent further life threatening deterioration of the patient’s condition.”

CPT-4 codes & descriptions copyright AMA. Refer to CPT-4 for complete definition.

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CPT Definition

Examples of vital organ system failure include, but limited to:

– central nervous system, – circulatory failure, – shock, – renal failure, – hepatic failure, – metabolic failure, and/or – respiratory failure.


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CMS Medical Review Criteria

• Clinical Condition Criterion

“There is a high probability of sudden, clinically significant or life threatening deterioration in the patient’s condition which requires the highest level of physician preparedness to intervene urgently.”

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CMS Medical Review Criteria

• Treatment Criterion“Critical care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent personal assessment and manipulation by the physician. Withdrawal of, or failure to initiate these interventions on an urgent basis would like result in sudden, clinically significant or life threatening deterioration in the patient’s condition.”

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Patients Who May Not Meet Critical Care Criteria

• Patients admitted to critical care unit due to bed shortage

• Patients admitted to critical care unit for close nursing observation and/or frequent monitoring of vital signs

• Patients admitted to critical care unit because hospital rules require certain treatment (e.g., insulin drips) to be administered in this location

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Coding Tips

• CPT definition applies for the adult, child and neonate critical care services

• Three types of CPT critical care codes:– Neonatal Critical Care– Pediatric Critical Care– Critical Care to patients over age 24 months

• CPT critical care codes are distinguished by:– age of patient– initial or subsequent care – day/hours of service rendered

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Discerning Critical Care Codes and

Required Documentation

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Critical Care Services

Neonatal and Pediatric Critical Care involves the management, monitoring and treatment of the patient, including:

– Enteral and parenteral nutritional maintenance– Metabolic and hematologic maintenance– Respiratory, pharmacologic control of the circulatory

system– Parent/family counseling– Case management services– Personal direct supervision of the health care team in the

performance of cognitive and procedural activities


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Neonatal Critical Care

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• CPT Codes 99295-99296 are used to report services provided by a physician directing the care of a critically ill neonate through the first 30 days of life

• Codes are reported once per day, per patient

• Care starts with the date of admission and ends once the neonate is no longer considered to be critically ill


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Services Rendered Codes

Initial Neonatal Critical Care, per day for the E/M of Critically Ill Neonate, 30 days of age or less 99295

Subsequent Neonatal Critical Care, per day for the E/M of Critically Ill Neonate, 30 days of age or less 99296


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Neonatal Intensive Care



Subsequent Intensive Care, per day for E/M of the recovering very low birth weight infant (present body weight <1500 grams) 99298

Subsequent Intensive Care, per day for E/M of the recovering very low birth weight infant (present body weight of 1500-2500 grams) 99299

Deleted CPT Code YR 2003 99297

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Pediatric Critical Care

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• CPT codes 99293-99294 are used to report services provided by a physician directing the care of a critically ill neonate/infant 31 days to postnatal age up through 24 months of age

• Reported by once per day, per patient

• Care starts with the date of admission and ends once the neonate is no longer considered to be critically ill


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Initial Pediatric Critical Care, per day for the E/M of Critically Ill Infant or Young Child, 31 days through 24 months of age 99293

Subsequent Pediatric Critical Care, per day for the E/M of Critically Ill Infant or Young Child, 31 days through 24 months of age 99294

CPT-4 codes & descriptions copyright AMA. Refer to CPT-4 for complete definition

New Codes for Year 2003:

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Documentation Requirements

• Medical records documentation must: – Reflect a critical illness or injury

– Describe the critical care services performed including, but not limited to:

• Medical/Family History obtained from and/or treatment options discussed with family members or surrogate decision makers

• Physical Examination• Patient care management and monitoring

– State the patient’s status and treatment for the entire time for which critical care services are billed (even when there is no change in treatment of the patient)

– Be documented by the rendering physician

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Coding Tips• Select neonatal and pediatric critical care codes

based on patient’s age at time of admission

• Report neonatal intensive care codes based on patient’s present weight (not birth weight)

• Use neonatal and pediatric subsequent critical care codes until patient is determined to no longer be critically ill (even if care goes beyond age stated in description)

• Use subsequent hospital care codes (i.e., 99231-99233) if patient is >2500 gm and not critically ill


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Adult Critical Care(Over 24 Months)

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Adult Critical Care• CPT codes 99291-99292 are used to report

critical care services provided to infants and young children over the age of 24 months

• Report 99291 for the first 30 – 74 minutes

• Assign 99292 for each additional 30 minutes beyond the first 74 minutes

• Do Not report critical care codes for services of less than 30 minutes in total duration


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Time TableTotal Duration of time CPT Codes

Less than 30 minutes (less than ½ hour) appropriate E/M codes

30 to 74 minutes (1/2 hr to 1 hr 14 min) 99291 x 1

75 to 104 minutes (1 hr 15 min to 1 hr 44 min) 99291 x 1 and 99292 x1

105 to 134 minutes (1 hr 45 min to 2 hr 14 min) 99291 x1 and 99292 x 2

135 to 164 minutes (2 hr 15 min to 2 hour 44 min) 99291 x 1 and 99292 x 3

165 to 194 minutes (2 hr 45 min to 3 hr 14 min) 99291 x 1 and 99292 x 4

195 or more minutes (3 hr 14 min – etc) 99291 and 99292 as appropriate


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Time Criteria for Critical Care

Included Activities Excluded Activities

Time spent on floor/unit in the care of a critically ill or injured patient

Time spent in activities that does not directly contribute to the care of a critically ill or injured patient

Time spent at the patient’s bedsideTime spent on indirect care, such as phone calls taken at home, office or elsewhere in hospital

Time Spent on floor/unit engaging in work directly relating to the patient

Time spent providing care to other patients, either in CCU or elsewhere

Time spent on floor/unit discussing patient's care with other staff

Time spent with residents on rounds or other venues discussing the patient

Time spent on floor/unit documenting the performance of specific services, clinical findings, and orders

Time spent performing procedures not bundled in critical care services

Time spent on floor/unit with family or surrogate decision makers when the discussion bears directly on the medical decision making because patient is unable to participate

Time spent with family members or other surrogate decision makes when patient is competent to make medical decisions

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Documentation Requirements• Medical records documentation must:

– Include a critical illness or injury and the critical care activities that were performed

– State time spent in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit, including time spent on the floor or unit with family members or surrogate decision makers

– Describe the patient’s status and treatment for the entire time for which critical care services are billed (even when there is no change in treatment of the patient)

– Be documented by the rendering physician

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Bundled Services

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Bundled Services• CPT manual states that the following services are

included in all critical care services:

– Cardiac Output Measurements (93561, 93562)– Chest X-rays (71010, 71015, 71020)– Pulse Oximetry (94760, 94761, 94762)– Blood Gases, & information in Computer (99090)– Gastric Intubation (43752, 91105)– Temporary Transcutaneous pacing (92953)– Ventilatory Management (94656-94662)– Vascular Access Procedures (36000,36410,36415,36540,

36600)

• Any other service performed not listed above may be reported separately


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NICU/PICU Bundled Services

• Umbilical venous (36510)

• Umbilical arterial (36660)

• Central catheters (36488, 36490)

• Peripheral vessel catheterization (36000)

• Arterial catheters (36140, 36620)

• Oral or nasogastric tube (43752)

• Endotracheal Intubation (31500)

• Lumbar puncture (62270)

• Suprapubic bladder aspiration (51000)

• Bladder catheterization (53670)

• Ventilation management (94656, 94657)

• Continuous positive airway pressure CPAP (94660)

• Administration of IV fluids (90780, 90781)

• Blood transfusion components (36430, 36440)

• Vascular punctures (36420, 36600)

• Invasive or non-invasive electronic monitoring of vital signs, bedside pulmonary function testing (94375)

• Blood gases or oxygen saturation (94760-94762)

CPT manual designates the following additional services as components of neonatal and pediatric critical care services:


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Coding Tips• Assign neonatal or pediatric critical care codes

once per day, per patient

• Consolidate and report adult critical care codes (even when critical care is rendered in intermittent episodes on a given day)

• Report separately any procedure that is not bundled into critical care codes. (Do not include the procedure time when assigning adult critical care codes)

• Only one physician may bill for a given hour of critical care even if more than one physician is providing care to a critically ill or injured patient

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Additional Physician Services

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Additional Physician Services

Services Rendered CodesPhysician Standby Service, requiring prolonged physician attendance, each 30 minutes 99360

Attendance at delivery and initial stabilization of newborn 99436

Newborn Resuscitation: provision positive pressure vent &/or chest compressions in the presence of acute inadequate vent &/or cardiac output 99440


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Physician Standby Services

• CPT Code 99360 requires:– Standby services requested by another physician– Prolonged physician attendance without direct face-to-face

contact with the patient– Thirty (30) minutes or more of time spent standing by

• Total duration of time spent by a physician on a give date of standby should be documented and reported

• The physician can not:– Provide care or services to other patients during this time period– Report time spent proctoring another physician


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Physician Standby Services

• Physician standby services (99360) may be reported in addition to:

99295 – Initial day Neonatal Critical Care99431 – History and examination of the normal

newborn infant99440 – Newborn resuscitation

• Physician standby services may not be reported in addition to:

99436 – Attendance at delivery (when requested by delivering physician) and initial

stabilization of newborn


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Attendance at Delivery• CPT Code 99436 requires:

– Physician’s attendance at delivery requested by another physician– Actual pediatric care and services provided during the period of

attendance because the newborn may require immediate care (i.e., resuscitation, stabilization, or work up for potential problems, such as sepsis, respiratory distress or congenital defects)

• This code encompasses the associated physician services prior to, during, and immediately after the delivery of a newborn

• The physician can not provide care or services to other patients during this time period


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Attendance at Delivery

• Attendance at Delivery services (99436) may be reported in addition to:

99295 – Initial day Neonatal Critical Care

99431 – History and examination of the normal newborn infant

• Attendance at delivery may not be reported in addition to:

99440 – Newborn resuscitation


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Newborn Resuscitation

• CPT Code 99440 includes:– Positive-pressure ventilation and/or chest compressions in a neonate who

exhibits inadequate ventilation and/or cardiac output

– Suctioning (without intubation to remove mucus, blood, or meconium)

– Assisted ventilation (e.g., bag and mask)

– External cardiac massage

• All other life support measures performed are reported separately

• Intubation to suction meconium is reported separately with code 31500


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Newborn Resuscitation

• Newborn resuscitation services (99440) may be reported in addition to:

99295 – Initial day Neonatal Critical Care

99431 – History and examination of the normal newborn infant

• Newborn resuscitation code may not be reported in addition to:

99436 – Attendance at delivery (when requested by delivering physician) and initial

stabilization

of newborn


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Transporting a Critical Care Patient

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Pediatric Transport Codes

• CPT Code 99289– Critical care services delivered by a physician, face-to-

face, during transport to or from a facility (inter-facility) of critically ill or injured pediatric patient (24 months of age or less); first 30 to 74 minutes

• CPT Code 99290– “Add-on” code for each additional 30 minutes– List separately in addition to code for primary service


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Adult Transport Codes

• CPT Codes 99291-99292 should be reported for the physician’s attendance during the transport of critically ill or injured patients over 24 months of age to or from a facility or hospital.

• HCPCS Level II codes G0240 and G0241 were deleted in YR 2003 update.


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Parameters for Transport Codes

Included Excluded

Face-to-Face patient contact Not Critically ill or injured patient

Begins when physician takes responsibility Less than 30 minutes

Ends when receiving facility takes responsibility Two-way Communication

Services by other staff

Services separately billable

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Coding Tips• Use CPT codes 99289-99290 only when the:

– Patient’s condition must meets the critical care definition

– Transport is inter-facility (not within a facility)

AND– Time in transport is 30 minutes or longer

• Count only the time the physician spends in direct face-to-face contact with the patient during the transport


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Coding Tips• Report only services rendered by the physician.

(Do not include those procedures or services performed by other members of transport team)

• Review the bundled services for transport codes. (They are the same as those for all critical care codes)

• Assign 99288 for physician-directed EMS care. (Physician is located in hospital emergency or critical care department on 2-way voice communication)


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Non-critical Care Services

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Non-critical Care Services• Admission codes are used to report E/M services

for initial hospital care– Report only one time per admission– Require 3 of 3 key components

• CPT Code 99223– Admit high level E/M patient visit

• CPT Code 99222– Admit moderate level E/M patient visit

• CPT Code 99221– Admit low level E/M patient visit


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Non-critical Care Services

• Subsequent hospital care for E/M services – Require 2 of 3 key components– May be reported one time per day per provider

• CPT Code 99233– Subsequent high level E/M patient visit

• CPT Code 99232– Subsequent moderate level E/M patient visit

• CPT Code 99231– Subsequent low level E/M patient visit


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Modifiers

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Modifiers

New Modifier for Year 2003:

• Modifier –63– Procedure performed on Neonates and Infants up to a

present body weight of 4 kg – May involve significantly increased complexity and

physician work commonly associated with these patients

– Do not use this modifier with codes in the E/M, anesthesia, radiology, pathology or medicine sections


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Modifiers

• Modifier – 25– Indicates a significant, separately identifiable E/M

service performed by the same physician on the same day of a procedure or other service

• Modifier – GC– Identifies that the service was performed in part by a

resident under the direction of a teaching physician


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Common Pitfalls

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Reporting Critical Care

• Full Attention Required – Physician may not be providing

service to other patients • Reporting Physician Time

– Total time not documented – Documentation exhibits time

interrupted &/or continuous• Total Time Less Than Minimum

– Critical care reported when documented time is less than 30 minutes

• Time Other Than Face-to-Face– Services at patient’s bedside or

elsewhere on floor/unit included as long as work directly relates to the patient’s care.

• Other Physicians Services– More then one physician

reporting critical care code• Billable Procedures

– Time spent on other billable services/procedures included in total time

• Ventilator Management– Reporting procedure included

with critical care management• Medically Necessary

– Condition Support Critical Care Service

• Teaching Physician Rules– Resident or staff time included in

adult critical care total time

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Full Attention Required

• Adult critical care codes are used to report total duration of time spent by a physician providing critical care service

• Physician MUST devote his or her full attention to the patient

• Cannot provide services to any other patient during the same period of time

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Reporting Physician Time

• Time spent with the individual patient should be recorded in the patient’s chart

– Time must be documented legibly and unequivocally

– Time must involve activities directly related to critical care

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Total Time Less Than Minimum

• Adult Critical Care time of less than 30 minutes is not reported separately– Report other appropriate E/M code

• Adult Critical Care time may be continuous or interrupted

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Time Other Than Face-to-face

• Adult critical care time includes time spent engaged in work directly related to the critically ill or injured patient, whether at patient’s bedside or on floor/unit

• Document time spent on the floor or unit with family members or surrogate decision makers to:– Obtain a Medical History– Review the Patient’s condition or prognosis– Discuss treatment or limitations of treatment

• Documentation must show the conversation bears directly on the medical decision making process

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Other Physician Services

• Only one physician may bill for a given hour of Critical Care even if more than one physician is providing care to a critically ill or injured patient

• A physician must be prepared to demonstrate that the service and/or time billed meets the required criteria

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Billable Procedures

• Bundled services, when performed on the day of critical care, are included in the critical care service and not reported separately

• Any other service performed not identified as an inclusive procedure may be reported separately

• Review CPT definitions for included procedures, as well as edits under the Correct Coding Initiative (CCI) and policies by third-party payers for details

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Ventilator Management

• Ventilator management billed under physician fee schedule– CPT Codes 94656, 94657, 94660 and 94662

• Do not bill both Ventilator management and E/M code– Modifier -25 is not acceptable


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Medically Necessary

• Documentation must show that the patient’s condition meets the critical care definition

• Services for a patient who is not critically ill but happens to be in a critical care unit are reported using other appropriate E/M codes

• Do not report critical care codes when a patient is in a critical care unit because:– No other hospital bed is available– Close nursing observation &/or frequent monitoring of

vital signs is required– Hospital rules require certain treatments be provided

in critical care unit

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Teaching Physician Rules

• The teaching physician must be present for the period of time for which claim is made

• Time spent by the resident may not be counted as critical care time

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Questions and Answers

Darlene Ornburn, MBA, CPC, CCP

573-882-3295

Documents

Taking the Crisis Out of Pediatric Critical Care Coding