A 4-year-old, critically ill child is admitted to the PICU from the ED with respiratory failure due to an exacerbation of asthma not manageable in…

The patient is 4 years old and meets critical-care criteria (acute respiratory failure requiring continuous bronchodilator therapy, cardiovascular monitoring, and possible mechanical ventilation). CPT instructs that initial inpatient pediatric critical-care services for children aged 2 through 5 years are reported with 99471. Codes 99291-99292 are used for critical care of patients older than the pediatric range defined in CPT, while 99285 is an emergency-department service and not reportable once the child is admitted to the PICU. Code 99475 applies to children 6-11 years. Therefore, 99471 is the single, most specific E/M code for this encounter.

A. 99285 – High-level ED visit; not billable after transfer of care to PICU and inpatient status.

B. 99475 – Pediatric critical care initial, ages 6-11; patient is only 4.

C. 99291 – General critical care, but CPT directs use of pediatric codes (99468-99476) for patients ≤5 years.

1. AMA. CPT® Professional 2023

code descriptor 99471 and parenthetical notes

pp. 36-37.

2. AMA. CPT® 2023 “Critical Care Services and Pediatric Critical Care” guidelines

para. 3 under “Inpatient Neonatal and Pediatric Critical Care

” p. 35 (defines age ranges and code use).

3. American Academy of Pediatrics. “Management of Respiratory Failure in the PICU

” Pediatrics 144(2):e20192712

2019

Introduction (affirms respiratory failure constitutes critical illness). DOI:10.1542/peds.2019-2712.

4. Stanford University School of Medicine

Pediatrics ICU Course Notes

Section “Age-specific CPT Coding

” 2022

p. 4 (reinforces use of 99471 for 2-5 yr critical care).