PopQuiz: CPT codes and Age

[Ruth Sheets]

Julie, age 5 years 11 months and 29 days, is critically ill. She is an inpatient at a pediatric critical care facility. Dr. Swift provides initial pediatric critical care E/M services for her which took one hour 40 minutes. What's the CPT code(s)?
A. 99291, 99292
B. 99475
C. 99475, 99291, 99292
D. Either A or B will work.

See next post for the answer.

 

[Ruth Sheets]

Answer: First, it is important to realize that even though Julie is very close to her 6 year mark, she is still considered 5 years for the purposes of CPT. This means the proper E/M code is 99475.
BTW, had Julie been a full 6 years old, the following CPT guideline would apply. "Critical care services to a pediatric patient six years of age or older are reported with the critical care codes 99291, 99292." Looking at these codes, 99291 is for 30 - 74 minutes, and 99292 is an add-on code for each additional 30 minutes. Therefore, if Julie had been a full 6 years old at the time of service, the proper E/M CPT codes would be "99291,99292" to reflect the full 100 minutes of service.
Suggestion: make a note in your CPT book to remind yourself about figuring out ages. Example: 5yr 11mo is included in 5 yrs.

 

[Karen Fan]

This is a very good update, If I had read this and many other codes pertaining to age I would have thought that the age range for 99475 was only Up To age 5 not including age 5. The CPT code book states Initial inpatient pediatric critical care, per day , for the evaluation and management of a critically ill infant or young child, 2 through 5 years. Oh I get it, it does not say up-to 5 years. Just changed the notes in my book.

Thank You Karen Fan

 

[Ruth Sheets]

Karen, Good that you've figured this out... I went through the same thought process myself when I first encountered this situation.