2025 CPT code 99475
(Active) Effective Date: N/A Revision Date: N/A Evaluation and Management - Inpatient Pediatric Critical Care Evaluation and Management > Inpatient Neonatal Intensive Care Services and Pediatric and Neonatal Critical Care Services Feed
Initial inpatient pediatric critical care, per day, for a critically ill child aged 2-5 years.
Modifier 25 may be appended if a significant, separately identifiable E/M service was performed by the same physician on the same day.
Medical necessity requires that the patient's condition is truly critical, with a high probability of imminent life-threatening deterioration. The documentation must clearly support the need for the intensity of critical care services rendered. The services must be medically necessary and appropriate for the patient's condition.
The physician or qualified healthcare professional is responsible for the comprehensive evaluation, ongoing management, and treatment of the critically ill child aged 2-5 years. This includes constant monitoring, frequent interventions, and the development of an appropriate management plan.The physician's role necessitates complex decision-making to support vital organ system function(s).
- Evaluation and Management > Inpatient Neonatal Intensive Care Services and Pediatric and Neonatal Critical Care Services
- Inpatient Neonatal Intensive Care Services and Pediatric and Neonatal Critical Care Services
In simple words: This code covers the first day of intensive care in the hospital for a sick child between 2 and 5 years old. The doctor monitors the child closely, provides frequent care, and creates a treatment plan.
This CPT code reports the initial inpatient pediatric critical care services provided on a per-day basis for the evaluation and management of a critically ill infant or young child aged 2 through 5 years.It encompasses intensive observation, frequent interventions, and other intensive care services for a full calendar day.This code is reported only once per hospital admission. Subsequent days of critical care for the same admission are reported using code 99476.
Example 1: A 3-year-old child is admitted to the hospital with respiratory distress requiring mechanical ventilation. The physician provides continuous monitoring, adjusts ventilator settings, orders blood gases, and manages other aspects of the child's critical care for the initial day of admission. Code 99475 is reported., A 4-year-old child is admitted for septic shock requiring intravenous fluids, vasopressor support, and close monitoring of hemodynamic parameters. The physician manages the child's critical illness on the initial day of admission. Code 99475 is reported., A 2-year-old child is admitted with severe dehydration and electrolyte imbalances. The physician provides close monitoring, fluid resuscitation, and manages the child’s electrolyte derangements on the initial day of admission.Code 99475 is reported.
Detailed documentation is crucial. This must include the patient's age, admitting diagnosis, vital signs, description of the illness as critically ill, details of the interventions and treatments provided, the duration of time spent providing critical care, and the overall response to treatment.Supporting documentation might include lab results, imaging studies, and nursing notes.
** Always refer to the most current CPT manual and payer-specific guidelines for accurate coding and reimbursement.
- Revenue Code: M2C (Hospital Visit - Critical Care)
- RVU: The relative value units (RVUs) for this code will vary based on geographic location and other factors. Consult the CMS Physician Fee Schedule for current RVU values and payment rates.
- Global Days: This code represents a single day of critical care.Subsequent days are coded separately.
- Payment Status: Active
- Modifier TC rule: No Technical Component (TC) modifier applies to this code.
- Fee Schedule: Historical fee schedule data is unavailable in this response. Consult the CMS Physician Fee Schedule for historical data.
- Specialties:Pediatric Critical Care Medicine, Pediatrics, Neonatology
- Place of Service:Inpatient Hospital