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Hospital code question

Joaquin Posted Fri 14th of February, 2014 19:38:09 PM

If a child less than 5 mos old was admitted into ICU, then the doctor watched the child acutely for 1 hr before the patient was transferred to another facility where another provider assumed care. What CPT codes would be billed?

Would the critical care '99291' code be for one hour, if so then we could also select an Admit cpt code couldn't we? The code range 99468-99476 wouldn't apply in this case would it?

I read where if a neonate or infant becomes critically ill on a day when initial or subsequent intensive care services, hospital services, or normal newborn services have been performed by one individual and is transferred to a critical care level of care provided by a different individual in a different group, the transferring individual reports either the time-based critical care services performed (99291, 99292) for the time spent providing critical care to the patient, the intensive care service (99477-99480), hospital care services (99221-99233), or normal newborn service (99460, 99461, 99462) performed, but only one service. Would this paragraph apply in the above example?

Thank you -

SuperCoder Answered Mon 17th of February, 2014 19:19:14 PM


This has been transferred to our CE. Will reply soon.


SuperCoder Answered Wed 19th of February, 2014 20:29:44 PM

Thank you for your question!

Hourly critical care codes are the appropriate codes for the transferring physician to bill in this scenario, regardless of the age of the child. The critical care requirements, including the constant attention required for organ system failure or progression of organ system failure must be met. Keep in mind that at least 30 minutes of critical care must be provided before the first hour of critical care can be billed. Otherwise, the billing is all based on E/M codes.

The issue of billing a separate admission E/M code in this scenario must be carefully evaluated and addressed. The E/M service must be separately provided and documented, with no double dipping of critical care and E/M work or time. If the child just received critical care from the moment it was admitted, then all would be billed as time based critical care. However, typically, an admission E/M is provided and billed for in addition to the separate critical care time. There are also well defined procedures that are included in the critical care codes. These services should also not be separately billed, again this could constitute double dipping.

As always, meticulous documentation is necessary, including careful documentation of the time spent.


Torrey Kim, CPC, CGSC
Editor-in-Chief, Pediatric Coding Alert

Joaquin Posted Thu 20th of February, 2014 14:53:03 PM

So then the Critical Care Code, being 99291? Then subject to the documentation, possibly an Admit CPT code?

Thank you

Joaquin Posted Tue 25th of February, 2014 09:46:21 AM

Hi Torrey, I would just want to confirm my understanding from my post 4 days ago? Would you mind just confirming for me, thank you.

SuperCoder Answered Thu 27th of February, 2014 16:28:26 PM

No problem! Without seeing the exact documentation, we can't say for sure which codes apply to your case, but typically yes, if those codes are justified in your documentation, you can bill 99291 and the inpatient code. Payers do vary on whether they'll reimburse both, but you may want to contact your insurer up front and ask whether they want to see the documentation to support your claim, because some will request it for situations like this and it's better to be proactive than to have claims delayed. Thanks!

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