By Ticia Selmon, RHIA, CCS
The American Medical Association’s (AMA) Current Procedural Terminology (CPT) defines critical care the same way for adults, children, and neonates. However, confusion still lingers for some when it comes to knowing which critical care code to use for certain providers, specialties, age groups, and dates of service.
The key to assigning the appropriate critical care codes is understanding the definition of critical care as outlined by CPT, understanding code selection based on age, and partnering with providers to understand clinical terminology by specialty to have a greater understanding of when documentation supports services rendered or clarification is needed. Common mistakes are use or misuse of the daily codes vs. billed based on time spent with the patient when multiple specialties are involved. In addition, conflicting documentation related to when the patient is still critical but has had no changes.
Understanding CPT Guidelines
According to CPT guidelines, critical care medicine is “the direct delivery by a physician(s) or other qualified health care professional 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 that there is 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 to prevent further life-threatening deterioration of the patient’s condition.”
The following elements are required in order to assign a critical care code:
- Patient must be critically ill or injured
- One or more vital organ systems must be acutely impaired with high probability of imminent or life-threatening deterioration
- Prevention of further life-threatening deterioration must be done
The Center for Medicare and Medicaid Services (CMS) guidelines specifically indicate that both treatment of the vital organs and further prevention of deterioration must be met to qualify for critical care.
When assigning CPT codes for neonatal and pediatric critical care, code selection is based on meeting all criteria for critical care in addition to the age range of the patient.
In the inpatient setting:
- Neonatal critical care daily codes should be used for patients age 0 through 28 days (99468-99469)
- When a neonate is no longer critically ill yet still requires intensive services, assign the neonatal intensive care codes per CPT (99477-99480).
- Pediatric critical care daily codes should be used for patients age 29 days through five years (99471-99476)
- For patients six-years-old or older, time-based critical care codes should be used
In the outpatient setting:
- Time-based critical care codes should be used regardless of age (99291-99292)
For critical care transport:
- Pediatric critical care transport codes should be used for patients that are 24 months old or younger (99466-99467)
- Time-based critical care codes should be used for patients older than 24 months of age (99291-99292)
Using Daily Critical Care Codes Versus Time-based Codes
Daily critical care codes can only be billed once per day. All critical care services rendered on a single day by the provider or a provider of the same specialty will be captured in this single code. Any other critical care services rendered by providers of a different specialty must use the time-based critical care codes.
It is important to clearly define for providers the appropriate documentation needed for the daily codes versus the time-based codes when more than one provider specialty is providing critical care. The time-based code requires a time statement and the daily code does not. Clearly defining who will bill daily versus time-based critical care allows for the provider to start the clock for the time-based code. For example, a newborn is admitted to the neonatal intensive care unit (NICU) after delivery and is receiving critical care services from both a neonatologist and cardiologist. Since the newborn was admitted to the NICU service, the neonatologist would bill the daily critical care code (CPT 99468) and the cardiologist would bill a time-based critical care code (CPTs 99291-99292).
If it’s not readily apparent from documentation whether a case qualifies as critical care, coders should be querying the provider for clarity. It is also important for coding professionals to partner with providers that provide critical care services to more clearly understand key words or phrases that support critical care from a clinical perspective. Partnering with providers also allows coders the opportunity to provide feedback on common documentation errors that prevent critical care services from being coded. Using the previous example of a neonatologist and cardiologist providing critical care services on the same day, both need to meet the criteria for critical care to code for the service. However, what the neonatologist treated and managed for critical care will be different than what the cardiologist treated and managed. Understanding the key words and phrases utilized by the various provider specialties allows the coder to have a deeper understanding of when services have or haven’t met criteria for critical care.
Misconceptions About Critical Care Coding
The following statements are examples of misconceptions about critical care coding:
- Critical care can only be billed if a service was delivered in the emergency department resuscitation room or intensive care unit
- False, the location the critical care service was provided is not a determining factor for code selection
- Newborns or infants that present for emergent care are automatically critical care because of their age
- False, the age of the newborn or infant does not automatically make the emergent care critical care. Care rendered must meet the requirement of critical care to code.
- Provider A billed critical care so provider B can also bill critical care
- False, each provider’s service stands on its own—each provider needs to meet the criteria for critical care
Even with the limited evaluation and management codes available for neonatal and pediatric critical care coding, knowing when to use which code can get tricky. Best practice should be to frequently review CPT coding guidelines on critical care including neonatal and pediatrics and partner with your providers to have a mutual understanding of what needs to be documented.
Center for Medicare and Medicaid Services, MLN Matters MM5993, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5993.pdf.
American Medical Association, Current Procedural Terminology 2019, Evaluation and Management Services Guidelines, Pg. 23-25, 44-47.
American Medical Association, CPT Assistant, Critical Care Services Revisited, August 2019 pg. 8, 12.
Ticia Selmon (Ticia.Selmon@childrensmn.org) is the ambulatory coding manager at Children’s Minnesota.
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