Ped crit care age 2-5 init
CPT code 99475 covers the first day of intensive care management for critically ill or injured children aged 2 through 5 years who require constant physician supervision and advanced life support.
This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
NCCI bundling edits
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Billing tips
Bill 99475 only for the initial/first day of critical care; use 99476 for each subsequent day the patient remains in critical care status
Impact: Prevents automatic denials; incorrect sequencing causes 100% claim rejection and payment delays of 30+ days
Do not report 99475 on the same date as procedure codes that include critical care in their descriptor (e.g., cardiac catheterization, ECMO initiation)
Impact: Bundling edits will deny the critical care code; potential loss of $536.63 and risk of audit for unbundling
Ensure patient age is precisely documented as 2 years through 5 years (24 months to day before 6th birthday); wrong age code triggers denial
Impact: Age outside range requires different code (99471-99472 for neonates/infants, 99477 for initial intensive care neonate); incorrect code = automatic denial
Document all time spent by all physicians and qualified practitioners in the patient record; time by multiple providers can be aggregated if from same group/specialty
Impact: While not time-based for billing, documentation of comprehensive ongoing care throughout the day supports medical necessity; weak documentation risks $536.63 recoupment on audit
Separately report and document interfacility transport critical care (99466-99467) if applicable; these are additive when the same physician performs both
Impact: Can add $250-500+ when transport and PICU admission occur same day by same physician; requires separate time documentation
Verify the patient meets critical care criteria (not just ICU location); document specific organ system failures and interventions supporting critical illness
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