CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Inpatient Neonatal and Pediatric Critical Care Services coding and reimbursement

Guideline governing coding, documentation, and reimbursement for critical care services for neonates and pediatrics (under 24 months) billed to Neighborhood Health Plan of Rhode Island; applies to CMS-1500 submissions and place of service 21.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyInpatient Neonatal and Pediatric Critical Care Services coding and reimbursement

Policy CodePolicy N/A

Change TypeMinor editorial/formatting revision (9/1/2013)

Effective DateSeptember 1, 2010

Next Review DateN/A

Key ActionSubmit CMS-1500 claims for these services with documentation of time in the medical record and use Modifiers 24, 25 or 59 to indicate separately identifiable services when appropriate.

SourceLink

POLICY UPDATE CHANGES

Format change, minor edits were made on 9/1/2013.

2age groupings defined

CMS-1500claim form

POS 21place of service

24/25/59recommended modifiers

Critical Care Coverage Criteria

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyInpatient Neonatal and Pediatric Critical Care Services coding and reimbursement

Policy CodePolicy N/A

Change TypeMinor editorial/formatting revision (9/1/2013)

Effective DateSeptember 1, 2010

Next Review DateN/A

Key ActionSubmit CMS-1500 claims for these services with documentation of time in the medical record and use Modifiers 24, 25 or 59 to indicate separately identifiable services when appropriate.

SourceLink

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Critical care billing criteria

Covered when ALL of the following are met:

Care meets the definition of critical care: requires constant attendance or constant attention by the physician and the physician’s time is spent working on the critically ill patient; includes review of medical data, discussion with medical staff, and obtaining history/discussion with family when it directly contributes to medical decision-making.

ALL of the following

Included activities (examples)
- Review of medical data (laboratory, 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 the patient cannot contribute and the conversation directly contributes to medical decision-making.
Excluded activities (do not count toward critical care time)
- Routine family updates or emotional support conversations that do not directly contribute to medical decision-making.

Specified procedures and services are considered bundled into critical care per CPT and must not be billed separately (including but not limited to: umbilical venous and 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; continuous positive airway pressure (CPAP); surfactant administration; intravascular fluid administration; transfusion of blood components; invasive or noninvasive electronic monitoring of vital signs and bedside pulmonary function testing; monitoring or interpretation of blood gases or oxygen concentration).

Documentation: notation of time in the patient's medical record may be required to support billing for personal management/critical care services.

ALL of the following

Claims: This guideline applies to CMS-1500 claim submissions.
Place of service: Applies to place of service 21.
Modifiers: Use Modifiers 24, 25, or 59 to indicate a separately identifiable service; notes may be required to support separate payment.

Submission and Documentation Requirements

Documentation Required

Submission, documentation, and modifier requirements for CMS-1500 / POS 21

This guideline applies to CMS-1500 claim submissions and Place of Service 21. Documentation may be required to support personal management by the patient’s physician, including notation of time in the patient’s medical record. Modifiers 24, 25 or 59 should be used to indicate a separately identifiable service; notes may be required to support separate payment. Plan coverage, eligibility and claim payment edit rules may apply.

Apply guideline to CMS-1500 claim form submissions.
Use Place of Service 21 when billing inpatient facility-based services.
Document physician time in the medical record when billing for personal management/critical care.
Append modifier 24, 25, or 59 to identify separately identifiable services; retain supporting notes for audits or payment review.

Key Definitions

Critical care time

Definition of critical care timeConstant attendance or constant attention is a prerequisite; duration is the time the physician spent working on the critically ill patient, including review of medical data, discussion with staff, and obtaining history when it directly contributes to medical decision-making.

Included activitiesReview of medical data (labs, x-ray, other diagnostics)

Included activitiesDiscussion of the patient’s care with other medical staff in the unit or at the nurse’s station

Included activitiesObtaining medical history and discussion of treatment options with family when it directly contributes to medical decision-making

Excluded activities / documentation note

Excluded activitiesRoutine updating of the family about the patient’s condition or providing emotional support are not considered critical care.

Documentation requirementDocumentation of time in the patient’s medical record may be required to support personal management by the physician.

Billing notesModifiers 24, 25 or 59 should be used to indicate a separately identifiable service; notes may be required to support separate payment.

	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

OpenPayer

Inpatient Neonatal and Pediatric Critical Care Services coding and reimbursement

Critical Care Coverage Criteria

Coding and Age Definitions

Submission and Documentation Requirements

Key Definitions