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The pediatric and neonatal critical care codes include management, monitoring and treatment of the patient including respiratory, pharmacological control of the circulatory system, enteral and parental nutrition, metabolic and hematologic maintenance, parent/family counseling, case management services and personal direct supervision of the healthcare team in the performance of their daily activities.

These codes may routinely include any of the following services (therefore, these services would not be billed separately from the critical care codes):

• Umbilical venous or umbilical arterial catheters
• Central or peripheral vessel catheterization
• Other arterial catheters
• Oral or nasal gastric tube placement
• Endotracheal intubation
• Lumbar puncture
• Suprapubic bladder aspiration
• Bladder catheterization
• Initiation and management of mechanical ventilation or CPAP
• Surfactant administration
• Intravascular fluid administration
• Transfusion of blood components (excluding exchange transfusions)
• Vascular puncture
• Vascular access procedures
• Invasive or non-invasive electronic monitoring of vital signs
• Bedside pulmonary function testing
• Monitoring or interpretation of blood gases or oxygen saturation

Current Procedure Terminology (CPT) code 99468 and 99469 are used to report the services of directing the inpatient care of a critically ill neonate or infant 28 days or younger. These codes can only be used for neonates who are 28 days of age or less. Critically ill neonates require cardiac and/or respiratory support (including ventilatory or CPAP when indicated), continuous or frequent vital signs monitoring, laboratory and blood gas interpretations, follow-up physician re-evaluations, and constant observations by the healthcare team under direct physician supervision. This would also include immediate pre-operative evaluation and stabilization of neonates with life threatening surgical, or cardiac conditions.

CPT codes 99471-99476 are used to report the services of directing the inpatient care of critically ill infants or young children from 29 days of postnatal age through less than 6 years of age. Critically ill infants or young children also require cardiac and/or respiratory support (including ventilatory or nasal CPAP as indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician re-evaluations, and constant observation by the healthcare team under direct physician supervision. Immediate pre-operative evaluation and stabilization of infants or young children with life threatening surgical or cardiac conditions are included.

CPT code 99477 represents the initial day of inpatient care for the child who is not critically ill but requires intensive observation, frequent interventions, and other intensive care services.

When a physician is present for delivery and newborn resuscitation is required, CPT code 99465 may be reported in addition to the initial care, CPT 99468 or 99477.

Subsequent Intensive Care
CPT codes 99478 – 99480 are used to report care subsequent to the day of admission provided by a physician directing the continuing intensive care of the very low birth weight infant who no longer meets the definition of being critically ill. Low birth weight services are reported for neonates less than 2,500 grams who do not meet the definition of critical care but continue to require intensive observation and frequent services and intervention only available in an intensive care setting. Services provided to these infants exceed those available in less intensive hospital areas or medical floors. These infants require intensive cardiac and respiratory monitoring, continuous and/or frequent vital signs monitoring, heat maintenance, enteral and/or parental nutritional adjustments, laboratory and oxygen monitoring, and constant observation by the healthcare team under direct supervision.

The pediatric and neonatal critical care codes and the intensive (noncritical) low birth weight services codes would only be reported once per day per patient.

The following criteria should be used as guidelines for the correct reporting of neonatal and pediatric critical care codes for the subsequent care of critically ill neonate/infant (only one criteria is required to be classified as critically ill):

• Respiratory support by ventilator or continuous positive airway pressure (CPAP)
• Nitric oxide therapy (INOmax) or extracorporeal membrane oxygenation (ECMO)
• Prostaglandin, Inotropin, or chronotropic or insulin infusions
• Nil per os (NPO) with IV fluids
• Acute dialysis (renal or peritoneal)
• Weight less than 1,250 grams
• Acute respiratory deterioration with FI0² of 35% or greater by oxyhood

Optimum patient management requires frequent visits and ongoing supervision of the healthcare team by the physician in order to perform complex integrated decisions and applications for these children.

The following examples WOULD qualify as critical care:

• A neonate with a hypoplastic left heart syndrome not receiving mechanical ventilation, but requiring nitrogen, dopamine and prostaglandins to prevent death or immediate morbidity from hypertension or ductal closure
• A pre-catheter or pre-operative neonate who demonstrates cardiovascular and neurological stability who is admitted for the evaluation of a possible cardiac lesion
  (This child is currently on prostaglandin, pressors, and oxygen/nitrogen therapy.)
• A post-operative neonate who has not yet established normal urine output, who is at risk for post-anesthesia arrest, who has not regained normal bowel function, and whose blood pressure is unstable

Billing for Non-Critical Neonate/Infant or Premature Infant
The initial day of care for a non-critical neonate/infant or premature infant who is not admitted to the neonatal critical care unit should be billed using CPT codes 99221-99223.

Subsequent days of hospitalization for the non-critical neonate/infant or premature infant would be billed using CPT codes 99231-99233.

Last updated: September 14, 2016