Intensive Care Billing and Coding: A Comprehensive Guide

Intensive care billing and coding, especially within neonatal and pediatric settings, presents unique challenges and requires precise understanding of current guidelines. Traditionally, direct patient care in critical and intensive care units necessitated on-site provider presence. However, the Centers for Medicare and Medicaid Services (CMS) introduced temporary exceptions during the public health emergency, allowing for telemedicine provision of these services. It’s crucial for healthcare providers to stay updated with the latest CMS guidelines, particularly regarding the extension or expiration of these telehealth provisions.

Understanding On-site vs. Telemedicine in Intensive Care

While continuous 24/7 in-house physician attendance isn’t mandated for daily critical and intensive care coding, the assigned work Relative Value Units (wRVUs) for these codes are predicated on the assumption that the provider is physically present within the unit. This implies direct involvement in patient care, including active participation and supervision for a significant portion of the service duration. Therefore, detailed documentation in the Electronic Medical Record (EMR) is essential to justify critical or intensive care services, including medically appropriate examinations or assessments, and the provider’s active role in patient management.

Neonatal vs. Pediatric Critical Care Coding Distinctions

A notable difference exists in wRVUs between initial neonatal and pediatric critical care codes. Initial neonatal critical care codes (used for newborns up to 28 days postnatal age) carry a higher wRVU compared to initial pediatric critical care codes (for patients 29 days postnatal age and older). Subsequent critical care codes, however, maintain the same wRVU for both groups. For clarity, neonatal codes are applicable until the 28th postnatal day (day of birth being day 0), transitioning to pediatric codes from the 29th postnatal day onwards. For instance, an infant born on January 1st would be coded using neonatal codes until January 29th and pediatric codes starting January 30th.

It’s important to remember that initial neonatal (99468) and pediatric (99471) codes are designated for use only once per hospital stay, not per admission. Consider a case where a neonate admitted for hypoglycemia on postnatal days 0-2, requiring intensive care, subsequently develops sepsis on day 3 and necessitates intubation and inotropic support. In this scenario, an initial critical care code (99468) can be appropriately applied on postnatal day 3, even if initial intensive care was billed on days 0-2 for a different condition.

The initial neonatal intensive care code (99477) is age-dependent and strictly for neonates 28 days or younger, irrespective of weight. If an infant older than 28 days requires intensive care upon NICU admission, the appropriate initial day code should be 99223 (for complex medical decision making). Conversely, subsequent intensive care codes (99478-80) are weight-based and remain applicable beyond the neonatal period for infants weighing 5000 grams or less who continue to require intensive care.

Subsequent intensive care codes (99478-80) are dictated by the patient’s current weight. If a patient’s weight fluctuates, crossing a weight threshold associated with a specific code, the code corresponding to the daily weight should be utilized. For example, an infant born at 1500g admitted on Monday requiring intensive care (coded 99477). If the weight remains 1500g on Tuesday, code 99479 is used. However, if the weight drops to 1499g on Wednesday, the appropriate code becomes 99478.

Coding for Subsequent Intensive Care Beyond 5000g

Once an infant’s weight exceeds 5000g, subsequent intensive care codes are no longer applicable. In such cases, utilizing an appropriate subsequent hospital care code is recommended. Interestingly, the wRVUs for subsequent intensive care for infants weighing 2501-5000g (99480) and high complexity subsequent hospital care codes (99233) are comparable. It’s worth noting that initial intensive care (99477) and critical care codes (99468 and 99469) do not have weight restrictions and can be used for neonates weighing over 5000g if clinically appropriate.

Discharge coding (codes 99238 for ≤30 minutes and 99239 for >30 minutes) is time-based and uniform, regardless of the level of care provided during the hospital stay. No other daily bundled codes can be billed on the discharge day, irrespective of discharge time. These discharge codes encompass time spent on discharge examination, discussions with parents or guardians, discharge planning, communication with follow-up care providers, prescription preparation, referral forms, and discharge record completion. This time can be cumulative throughout the discharge day. Documenting specific time (e.g., 45 minutes) is preferable to simply stating “>30 minutes”. These same codes are applicable on the day of patient death.

Transfer of Care Billing and Coding Scenarios

In scenarios involving patient transfers within the same facility but to a different location, managed by the same physician group and subspecialty, a single daily global care code is applied. Similarly, a single daily global care code is used when a patient is transferred to a different facility but remains under the care of the same physician group. However, in situations involving acute or elective transfers between facilities and care is assumed by a different physician/Qualified Healthcare Professional (QHP) group, specific guidelines apply.

1. Acute transfer to a higher level of care: When a critically ill patient is acutely transferred and a different medical group assumes care, the transferring physician uses hourly critical care codes (99291-99292). The accepting physician or QHP at the higher level facility can then bill a daily global critical care code (99468 or 99471). Conversely, if a patient not requiring critical care is transferred (e.g., a stable infant transferred for a specific procedure), the transferring physician uses a hospital care code (99231-99233). If the accepting physician initiates critical care upon arrival (e.g., intubation for surgery), they can bill for critical care services.

2. Back-transfer to a lower level of care: When a patient is transferred back to a lower level of care (e.g., back to a community hospital after stabilization), the transferring physician at the higher acuity facility uses a routine care code (99231-99233). The receiving physician at the community hospital can then bill a daily global intensive care code (99478-99480) or hospital care code (99231-99233) as appropriate. If the patient still requires critical care during back-transfer, the transferring physician uses hourly critical care codes, and the receiving physician uses a global critical care admission code.

3. Insurance Considerations: It’s important to note that some payers might deny daily global codes billed by two different physician groups on the same day, potentially leading to claim denials.

In summary, coding principles for transfers emphasize that transferring providers generally do not use daily critical or intensive care codes (with a specific exception noted below). Receiving providers typically utilize daily codes.

1. Critical Care Transfer: When a critically ill patient improves and is transferred to a lower level of care within the same facility to a different provider group, the transferring provider reports subsequent hospital inpatient or observation care (99231–99233) or time-based critical care services (99291–99292), as clinically appropriate. The receiving provider then reports subsequent daily critical care (99469 or 99472), subsequent intensive care (99478–99480), or subsequent hospital inpatient or observation care (99231–99233) based on the patient’s condition.

2. Intensive or Routine Care Transfer: When a patient improves after the initial intensive care day and no longer requires intensive care and is transferred to a lower level of care, the transferring provider reports subsequent hospital inpatient or observation care (99231–99233) or subsequent normal newborn care (99460, 99462). An exception exists for transfers on the initial day of intensive care. If transfer occurs on the same day initial intensive care was provided by the transferring provider, code 99477 may be reported. The receiving provider then bills a global intensive care code (99478–99480) or hospital care code (99231–99233) as appropriate.

3. Discharge Codes and Transfers: Discharge codes (99238–99239) are not applicable for transfer scenarios as the patient is not being discharged home.

Car seat testing codes (94780 for the first 60 minutes and +94781 for each additional 30 minutes) can be billed in conjunction with hospital care codes (99231–99233), normal newborn codes (99460–99463), or discharge codes (99238–99239), but are not to be used with subsequent intensive care codes (99478–99480).