CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Inpatient Neonatal and Pediatric Critical Care Services reimbursement

This document governs coding, documentation, and reimbursement guidance for inpatient neonatal and pediatric critical care services for providers submitting CMS-1500 claims to Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyInpatient Neonatal and Pediatric Critical Care Services reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionUse modifiers 24, 25, or 59 on CMS-1500 claims for place of service 21 to indicate a separately identifiable service and include supporting notes if required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2neonatal/pediatric age groupings described

multiplebundled procedures listed

CMS-1500claim form

POS 21place of service

Coverage and Billing Rules for Inpatient Neonatal & Pediatric Critical Care

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Critical care coverage and billing rules

Coverage stance and documentation/billing expectations for critical care services:

ALL of the following

Constant attendance or constant attention is a prerequisite for care to be considered critical care; duration is the time the physician spent working on the critically ill patient (includes review of medical data, discussion with staff, obtaining history and family discussions that directly contribute to medical decision-making).
Included activities (examples)
- Review of medical data (lab, x-ray, or other diagnostic tests).
- Discussion of the patient's care with other medical staff in the unit or at the nurse's station.
- Obtaining medical history and discussion of treatment options with family/guardian when it directly contributes to medical decision-making (routine updates or emotional support are not critical care).
- Procedures and management typically bundled into critical care per CPT, including but not limited to: umbilical venous and umbilical arterial catheters; other arterial catheters including central or peripheral catheterization; vascular access procedures; vascular punctures; oral or nasogastric tube placement; endotracheal intubation; lumbar puncture; suprapubic bladder aspiration; bladder catheterization; ventilatory management; CPAP; surfactant administration; intravascular fluid administration; transfusion of blood components; invasive or noninvasive electronic monitoring of vital signs; bedside pulmonary function testing; monitoring or interpretation of blood gases or oxygen concentration.
Documentation may be required to support the personal management by the patient's physician, including notation of time in the patient’s medical record.
Payment may be made for critical care services in any location as long as the care meets the definition of critical care.
For claim submission: applies to CMS-1500 claim submissions and place of service 21.
Use modifiers 24, 25 or 59 to indicate a separately identifiable service; notes may be required to support separate payment.

Age groupings for inpatient neonatal and pediatric critical care: under 28 days; 29 days to 24 months.

Bundled Procedures and Code Guidance

Bundled procedures with critical caremixedCovered

Umbilical venous and umbilical arterial catheters	Umbilical venous and umbilical arterial catheters
Other arterial catheters, including central or peripheral catheterization	Other arterial catheters, including central or peripheral catheterization
Vascular access procedures	Vascular access procedures
Vascular punctures	Vascular punctures
Oral or nasogastric tube placement	Oral or nasogastric tube placement
Endotracheal intubation	Endotracheal intubation
Lumbar puncture	Lumbar puncture
Suprapubic bladder aspiration	Suprapubic bladder aspiration
Bladder catheterization	Bladder catheterization
Ventilatory management	Ventilatory management

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Claims Submission, Modifiers, and Provider Billing Actions

Billing Rule

Claims submission and modifier use for CMS-1500 / POS 21

This applies to CMS-1500 claim submissions for services rendered in Place of Service 21. Use modifier 24, 25, or 59 to indicate a separately identifiable service; supporting documentation/notes may be required to justify separate payment.

Apply to CMS-1500 claim form submissions.
Apply when Place of Service = 21.
Append modifier 24, 25, or 59 to indicate a separately identifiable service.
Be prepared to provide chart notes or time documentation if requested to support separate payment.

Key Definitions: Critical Care and Age Groupings

inv-04: Critical care (neonatal/pediatric)

DefinitionCritical care requires constant attendance or constant attention; the duration of critical care time is the time the physician spent working on the critically ill patient.

Included activitiesReview of medical data (lab, x‑ray, or other diagnostic tests) can be counted toward critical care time.

Team communicationDiscussion of the patient's care with other medical staff in the unit or at the nurse's station can be included in critical care time.

Family discussionsObtaining medical history and discussion of treatment options with family/guardian may be included if the conversation directly contributes to medical decision‑making; routine updates or emotional support are not included.

inv-05: Age groupings

NeonatalUnder 28 days.

Infant/Toddler29 days to 24 months.

ApplicationAge groupings apply to inpatient neonatal and pediatric critical care services for coding and reimbursement.