CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Pediatric Critical Care Transport — Billing and Reimbursement Guideline

Guideline governing coding, documentation, and reimbursement for pediatric critical care transport services for patients 24 months of age or younger, and instructions for providers submitting claims to Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPediatric Critical Care Transport — Billing and Reimbursement Guideline

Policy CodePolicy N/A

Change TypeClarified (format/minor editsadded language for 99485/99486)

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionDo not report other services by the control physician for the same time period and document actual times of care in the medical and transport records.

SourceLink

POLICY UPDATE CHANGES

Format change, minor edits, addition of language for codes 99485 and 99486.

24 monthsmaximum patient age this guideline applies to

>=30 minphysician attendance threshold

15 minminimum time to report

99446/9946Z/99485/99486key CPT codes

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Coverage criteria and billing rules

Covered when ALL of the following are met:

ALL of the following

Patient age 24 months or less on the date of service.
Physician attendance meets time thresholds for pediatric critical care transport codes: use the Evaluation and Management transport codes when physician face-to-face attendance exceeds 30 minutes; if less than 30 minutes, select a more appropriate E/M code.
Use CPT code 99446 for critical care services delivered by a physician, face-to-face, during inter-facility transport of a critically ill or injured pediatric patient (24 months or younger) for the first 30–74 minutes of hands-on care during transport; report 9946Z for each additional 30 minutes (add-on).
Control physician supervision codes: use 99485 for the first 30 minutes of control-physician supervision (includes two-way communication, data interpretation and report, and advice to the transport team); report 99486 for each additional 30 minutes (add-on).
Do not report services less than 15 minutes (these are time-related codes).
Document actual times of care and service in the medical record and ambulance/transport records; documented times should correlate.
Non face-to-face care for control physician supervision begins with first contact between the control physician and the transport team and ends when patient responsibility is assumed by the receiving facility.
Do not report any other services performed by the control physician for the same time period; do not report these supervision/transport codes if the same physician has billed codes 99466 or 99467.
The following are considered components of Pediatric Critical Care Transport and are not to be reported separately (examples): routine vital signs and cardiac monitoring; interpretation of chest x‑rays; interpretation of cardiac output measurements; interpretation of pulse oximetry; gastric intubation; interpretation of blood gases and stored data (ECGs, blood pressures, hematologic data); temporary transcutaneous pacing; vascular access procedures; ventilator management.
Bill appropriate ambulance modifiers on the trip code; this guideline applies to CMS‑1500 submissions and place of service 41. Specific product-line provisions on the payer website may apply.

Note: Time-based supervision codes (99485/99486) include two-way communication with the transport team, data interpretation, and reporting; 99485 covers the first 30 minutes, 99486 covers each additional 30 minutes (list separately).

CPT Codes and Time Thresholds

Pediatric critical care transport CPT codesCPTCovered

99446	Critical care services delivered by a physician, face-to-face, during an inter-facility transport of critically ill or critically injured pediatric patient; 24 months of age or less; first 30-74 minutes of hands on care during transport
9946Z	Each additional 30 minutes. (List separately in addition to code for primary procedure)
99485	Supervision by a control physician of inter-facility transport care of the critically ill or critically injured pediatric patient; 24 months of age or younger, includes two-way communication with transport team before transport; at the referring facility and during the transport; including data interpretation and report; first 30 minutes
99486	Supervision by a control physician of inter-facility transport care of the critically ill or critically injured pediatric patient; 24 months of age or younger, includes two-way communication with transport team before transport, at the referring facility and during the transport; including data interpretation and report; each additional 30 minutes (List separately in addition to code for primary procedure)

Time thresholds for reporting

Physician face-to-face thresholdUse pediatric critical care transport E/M codes when physician attendance exceeds 30 minutes

Supervision code reportingReport 99485 for the first 30 minutes of control physician supervision and 99486 for each additional 30-minute increment (list separately)

Minimum reportable timeDo not report services less than 15 minutes

If under thresholdIf physician attendance is less than 30 minutes, select a more appropriate Evaluation and Management code

Documentation requirementDocument actual times of care in the medical record and ambulance/transport records; times should correlate

Billing Restrictions and Claim Submission

Billing Rule

Control physician — do not report concurrent or duplicate services

Do not report any other services performed by the control physician for the same time period; do not report if the same physician has billed for codes 99466 or 99467. Services shorter than 15 minutes are not reportable. Document actual times of care in the medical record and ambulance/transport records; times should correlate.

Do not report other services by the control physician for the same time period.
Do not report if the same physician billed codes 99466 or 99467.
Do not report services less than 15 minutes.
Document actual times of care in medical and transport records; ensure times correlate.

Documentation Required

Claim submission and ambulance modifiers

Submit claims on the CMS-1500 form for place of service 41 and bill the appropriate ambulance modifiers on the trip code as required.

This guideline applies to CMS-1500 claim submissions.
This guideline applies to place of service 41.
Bill appropriate ambulance modifiers on the trip code.

Non Face-to-Face Care Definitions

Non face-to-face care (short definition)

DefinitionNon face-to-face care: activities by the control physician that do not occur in hands-on, face-to-face attendance during transport

IncludesTwo-way communication with the transport team and data interpretation performed by the control physician

Documentation noteThese non face-to-face activities are time-related and must have actual times recorded in the medical and transport records

Non face-to-face care — start and end of episode definition

Episode startBegins with first contact by the control physician with the transport team

Episode endEnds when patient responsibility is assumed by the receiving facility

ContextApplies to supervision codes (e.g., 99485/99486) and related time documentation