Tips for Handling Critical Care Evaluation for Pediatric Medical Billing Claims

Pediatrics is one of the most complex areas of medical billing. It has many medical billing codes that were created just for the use of describing procedures. However, there are other areas of medical billing that do not have these specific codes for children. This can make coding hit or miss unless you know the nuances of what the carrier wants in order to get the maximum reimbursements for procedures performed. A common dilemma is with CPT code 99293 and its use for outpatient emergency room exams for an infant or if code 99291 should be used.

The medical billing code 99291 means critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. You would use this code if a patient came into the emergency room and was there for a half and hour up to 74 minutes. This is pretty straight forward in medical billing. The confusion comes in when using code 99293. This means Initial inpatient pediatric care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age. This code should only be used if the infant is admitted inpatient.

When doing medical billing it becomes confusing because there is no code specifically for outpatient emergency room visits for children. There is only a child specific medical billing code for inpatient visits. A simple rule of thumb in medical billing is that the location of service must match the CPT code. This is because inpatient evaluations get reimbursed at different levels then outpatient emergency room visits.

If your staff is getting overwhelmed at the paperchase of keeping up with the current codes or you’re experiencing denials or partial payments of your medical billing claims; it may be time to consider outsourcing your medical billing to a partner that can make sure the latest coding regulations are followed and your practice receives the maximum reimbursements allowed for procedures performed.

View all Articles by: Melissa Clark, CCS-P