Transferring a Sick Baby to Another Hospital

Question:

Our pediatric group practices in a community hospital, without an NICU. My pediatrician was called to attend a delivery of a newborn who was born premature and in respiratory distress. The baby needed to be stabilized and transferred to a level III neonatal intensive-care unit. The pediatrician spent 90 minutes from the time the baby was born, and she began the assessment and interventions, until the baby left for the NICU in another hospital. was. The baby was never admitted to our hospital, so I can’t bill the initial hospital service codes. What can we bill that reflects the work of our physician?

Answer:

Report critical care codes 99291, +99292 based on the time spent caring for the baby. In this case, bill 99291 and 99292 x1 unit.

The neonatologist who cares for the baby in the NICU will report neonatal critical care codes in the series 99468—99476 for care of the baby for a calendar day.

Transferring patients to a higher acuity hospital

For a newborn or child being transferred to another facility, who is critically ill, use the critical care codes 99291—99292.

Critical care is time-based, defined as per hour or per additional 30 minutes.  For critically ill neonates being treated and not transferred, see the section below, “critically ill neonates.”

Many physicians and pediatric coders are unaware that they may use critical care codes 99291 and 99292 for neonates when the criteria for critical care are met.

Use 99291—99292 for all critical care for children six or older, as well.

CPT® says,

“Also report 99291—99292 for neonatal or pediatric critical care services provided by the individual providing critical care at one facility but transferring the patient to another facility. Critical care services provided by a second individual of a different specialty not reporting a per day neonatal or pediatric critical care code can be reported with codes 99291, 99292.”[1]

Document the time in caring for the critically ill baby before the baby is transferred and use these critical care codes to report the service.  The receiving hospital will report the per day critical care codes.

CPT® says that in order to bill ED visits, hospital inpatient or observation care, initial day neonatal intensive or critical care, the patient must be admitted to the ED or facility.

Document the time caring for the critically ill baby or child in the medical record.

Pediatric transport

There are codes defined by CPT® to report the “physical attendance and direct face-to-face care by a physician during the interfacility transport of a critically ill or critically injured patient 24 months of age or younger.” If the physician goes in the transport with the baby or child, use codes 99466–99467.  These codes are for use with patients who are critically ill or injured. The time begins when the physician assumes primary responsibility at the referring facility and ends when the receiving facility accepts the care of the patient.  Only direct, face-to-face physician time may be counted.

These codes may be used for neonates who require transfer to a higher acuity facility.

The CPT® book identifies specific other services that may not be billed in addition to pediatric transport. These are bundled into critical care.

These are:

• routine monitoring evaluations (eg, heart rate, respiratory rate, blood pressure, and pulse oximetry),
• the interpretation of cardiac output measurements (93598),
• chest X-rays (71045, 71046),
• pulse oximetry (94760, 94761, 94762),
• blood gases and information data stored in computers (eg, ECGs, blood pressures, hematologic data),
• gastric intubation (43752, 43753),
• temporary transcutaneous pacing (92953),
• ventilatory management (94002, 94003, 94660, 94662), and
• vascular access procedures (36000, 36400, 36405, 36415, 36591, 36600).

Any services performed which are not listed above should be reported separately.

See the critical care coding guide for more detail about coding critical care services.

There are also codes for non-face-to-face supervision by a control physician that includes two-way communication during transport, 99485 and 99486. (See your CPT® book for the description.) These have a status indicated of bundled in the Medicare fee schedule, and many Medicaid contractors and private insurance companies follow these status indicators and will not pay for the non-face-to-face service described by 99485 and 99486.

[1] CPT® 2025 Professional Edition, AMA, p. 24

CodingIntel members can download the Newborn and Pediatrics Coding Guide for a detailed review of these services.

The CPT^® quotes are from the critical care section of the book.

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