CPT 99472, 99472, 99476 BILLING restriction and limitations

Pediatric and Neonatal Critical Care

99472 Subsequent Inpatient Pediatric Critical Care per day, for the evaluation and management
of a critically ill infant or young child, 29 days through 24 months of age

NOte :Not valid for ages 28 days or less, can be billed by any physician provider type

99475 Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age

May be billed by any physician provider type

99476 Subsequent inpatient pediatric critical care, per day, for the evaluation and management of
a critically ill infant or young child, 2 through 5 years of age

May be billed by any physician provider type


LIMITATIONS:

• Pediatric, neonatal critical care codes and intensive (non-critical) low birth weight service codes are reported once per day per recipient.

• Subsequent Hospital Care codes (99231-99233) cannot be billed on the same date of service as neonatal critical care codes (99468-99476)

 • Only one unit of critical care can be billed per child per day in the same facility. Medicaid pays the first claim received and denies subsequent claims (first in, first out policy).

• Critical care is considered to be an evaluation and management service. Although usually furnished in a critical or intensive care unit, critical care may be provided in any inpatient health care
setting. Services provided which do not meet critical care criteria, should be billed under the appropriate hospital care codes. If a recipient is readmitted to the NICU/ICU, the provider must be the primary physician in order for NICU critical care codes to be billed again.

• Once the patient is no longer considered by the attending physician to be critical, the Subsequent Hospital Care codes (99231-99233) should be billed. Only one unit can be billed per day per physician regardless of specialty. Medicaid pays the first claim received and denies subsequent claims (first in, first out policy).

• Transfers to the pediatric unit from the NICU cannot be billed using critical care codes. Subsequent hospital care would be billed in these instances.

• Global payments encompass all care and procedures that are included in the rate. Providers may not perform an EPSDT screen and refer to a partner or other physician to do procedures. All
procedures that are included in the daily critical care rate, regardless of who performed them, are included in the global critical care code.

• Consultant care rendered to children for which the provider is not the primary attending physician must be billed using consultation codes. Appropriate procedures may be billed in addition to
consultations. If, after the consultation the provider assumes total responsibility for care, critical care may be billed using the appropriate critical care codes as defined above. The medical
record must clearly indicate that the provider is assuming total responsibility for care of the patient and is the primary attending physician for the patient.

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