Ped crit care age 2-5 init
CPT code 99475 is billed when a critically ill child between 2 and 5 years old receives intensive monitoring and treatment on the first day of pediatric critical care. This involves constant bedside attention from medical staff in an intensive care setting.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Verify patient age is between 2 years 0 days and 5 years 364 days at time of service - age miscalculation is a top denial reason
Impact: Age errors result in 100% claim denial; correct code selection based on age (99468 for <2 years, 99291 for 6+ years) is essential for the full $536.63 reimbursement
Bill only once per calendar day regardless of hours spent - 99475 is date-of-service based, not time-based like adult critical care
Impact: Prevents duplicate billing denials; attempting to bill multiple units or combining with 99476 on same date causes automatic rejection
Use 99476 for each subsequent day of critical care - never bill 99475 more than once per admission for the same patient
Impact: 99476 pays $473.87 (2025 rate); billing 99475 on subsequent days triggers bundling edits and claim rejection
Do not separately bill procedures bundled into critical care codes (central lines, ventilator management, chest tubes, arterial lines, gastric intubation, temporary pacing)
Impact: Unbundling violations can result in recoupment of $150-$800 per procedure plus potential fraud investigation
Document medical necessity for critical care level of service including specific instability indicators and interventions required
Impact: Downgrades to subsequent hospital care codes (99232-99233 paying ~$109-$165) occur in 15-20% of audits lacking proper critical status documentation
Only one physician per specialty group can bill critical care per calendar day - coordinate with hospitalists and subspecialists
Impact: Split/shared critical care billing not allowed; second physician must use consultation or subsequent hospital care codes at significantly reduced reimbursement
Common denials
Patient age outside 2-5 year range at time of service
How to appeal: Submit medical records clearly documenting date of birth and service date showing patient was 2-5 years old. If age miscoded, resubmit with correct code (99468 for <2 years, 99471-99472 for 29 days-24 months, 99291-99292 for 6+ years) rather than appealing.
Medical necessity not supported - patient condition did not meet critical care criteria
How to appeal: Provide detailed clinical documentation showing high probability of life-threatening deterioration requiring frequent physician assessments, vital sign instability, vasoactive medications, mechanical ventilation, or other intensive interventions. Include nursing flow sheets showing continuous monitoring and physician progress notes documenting critical status.
Duplicate billing - 99475 billed on multiple days or with 99476 on same date
How to appeal: Verify dates of service; if legitimately different calendar days, submit corrected claim with 99475 for initial day only and 99476 for each subsequent day. If same-day duplicate, withdraw one claim.
Bundled procedures billed separately (central line placement, intubation, arterial line)
How to appeal: Review CCI edits; most procedures are bundled into 99475. If procedure was performed by different specialty group or meets modifier 59 criteria (rare), submit documentation supporting separate session/encounter. Otherwise, accept bundling per Medicare policy.
Frequently asked questions
What is the Medicare reimbursement for CPT code 99475 in 2025?
The 2025 Medicare national average payment for CPT 99475 is $536.63 for both facility and non-facility settings. This is based on 16.59 total RVUs (11.25 work RVU, 4.43 PE RVU, 0.91 MP RVU) multiplied by the 2025 conversion factor of 32.3465.
What age range qualifies for CPT code 99475?
CPT 99475 is specifically for pediatric patients aged 2 years 0 days through 5 years 364 days (up to the 6th birthday). Use 99468 for neonates/infants under 28 days, 99471-99472 for 29 days through 23 months, and adult critical care codes 99291-99292 for patients 6 years and older.
Can you bill 99475 and 99476 on the same day?
No, you cannot bill both 99475 and 99476 on the same calendar day. CPT 99475 is for the initial day of critical care only, and 99476 is for each subsequent day. Bill 99475 once on the first date of critical care, then 99476 for each following calendar day the patient remains critically ill.
How many RVUs is CPT code 99475 worth?
CPT 99475 has 16.59 total RVUs in 2025, consisting of 11.25 work RVUs, 4.43 practice expense RVUs (same for facility and non-facility), and 0.91 malpractice RVUs. This is among the highest RVU values for pediatric evaluation and management codes.
What procedures are bundled into CPT 99475?
CPT 99475 includes numerous bundled services that cannot be separately billed: central venous and arterial catheter placement, endotracheal intubation, nasogastric/orogastric tube placement, bladder catheterization, chest tube insertion, temporary pacemaker insertion, ventilator management, vascular access procedures, and interpretation of cardiac output measurements. These are considered integral to critical care.
Who can bill CPT code 99475?
Physicians and qualifying non-physician practitioners (in states allowing independent practice) with critical care privileges can bill 99475. Typically this includes pediatric intensivists, pediatricians with PICU privileges, and pediatric emergency physicians providing critical care. Only one physician per specialty group can bill per calendar day.
What documentation is required for CPT 99475?
Required documentation includes patient age verification (2-5 years), clear critical illness diagnosis, evidence of hemodynamic instability or high risk of deterioration, specific critical care interventions performed, physician presence and frequent reassessment throughout the day, medical necessity justification for PICU-level care, and care coordination notes. Time documentation is not required as 99475 is date-based, not time-based.