CPT 99476E&M

Ped crit care age 2-5 subsq

CPT code 99476 covers the daily critical care management for children between their 2nd and 5th birthdays who are seriously ill and need intensive monitoring in a pediatric ICU. This code is used for each day after the first day of critical care.

Showing rates for

National Average

Base Medicare rate

$325.41

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

Work RVU

6.75

PE RVU (NF)

2.73

MP RVU

0.58

Total RVU

10.06

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Bill once per calendar day, not per 24-hour period - if critical care spans midnight, bill appropriate code for each calendar day
Impact: Prevents underbilling of $325.41 when care extends across midnight; ensures capture of all compensable days
Verify exact patient age at time of service - 99476 is for ages 2-5 years; wrong age code selection is a top denial reason
Impact: Age 29 days-24 months uses 99472, age 6+ uses 99232-99236; incorrect code selection results in 100% denial or recoupment
Document all time spent and specific critical care activities including ventilator management, hemodynamic monitoring, and interpretation of multiple physiologic parameters
Impact: Comprehensive documentation reduces audit risk and supports medical necessity; vague notes are primary reason for $325.41 payment recoupment
Do not separately bill for bundled procedures (central line placement, ventilator management, gastric intubation, blood draws, chest x-ray interpretation, etc.) on the same day
Impact: Unbundling triggers automatic denials and potential fraud investigation; bundled services already included in $325.41 payment
Ensure only one physician per group bills per calendar day - if coverage changes, document clearly in medical record with time of service transfer
Impact: Multiple billings from same group trigger duplicate claim denials; clear handoff documentation prevents $325.41 payment rejection
For patients transferred between facilities, verify medical necessity for continued critical care level at receiving facility before billing 99476
Transfer without ongoing critical illness may require lower-level subsequent hospital care codes (99231-99233); inappropriate code selection risks entire $325.41 payment

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Frequently asked questions

What is the Medicare reimbursement rate for CPT code 99476 in 2025?

The 2025 Medicare national average reimbursement rate for CPT 99476 is $325.41 for both facility and non-facility settings. This rate is based on 10.06 total RVUs (6.75 work RVU, 2.73 PE RVU, 0.58 MP RVU) multiplied by the 2025 conversion factor of 32.3465.

What age range qualifies for CPT code 99476?

CPT code 99476 is used for pediatric patients aged 2 through 5 years (specifically 29 days through 23 months based on the descriptor, though labeled 2-5). Patients younger than 29 days require neonatal critical care codes (99468-99469, 99478-99480), while patients 29 days to 24 months use 99471-99472, and patients 6 years and older use standard critical care codes (99291-99292) or subsequent hospital care codes.

Can I bill CPT 99476 multiple times in one day?

No. CPT 99476 is billed once per calendar day regardless of the amount of time spent. It is a per-day code, not a time-based code. If care extends past midnight, you would bill 99476 for each separate calendar day of critical care provided.

What procedures are bundled into CPT 99476?

CPT 99476 includes numerous bundled services: interpretation of chest x-rays, blood gases, pulse oximetry, blood draws, gastric intubation, temporary transcutaneous pacing, ventilator management, vascular access procedures, endotracheal intubation, and routine monitoring. These cannot be separately billed on the same day as 99476.

What documentation is required to bill CPT 99476?

Documentation must include: patient age verification, critical illness requiring ICU-level care, detailed assessment of organ systems, specific critical care interventions (ventilator settings, pressors, etc.), patient response to therapy, changes in treatment plan, and physician presence/availability. Medical necessity must be clearly evident from the severity of illness documented.

What is the difference between 99476 and 99472?

99476 is for subsequent day critical care for children aged 2-5 years, while 99472 is for subsequent day critical care for infants and young children aged 29 days through 24 months. The age of the patient at the time of service determines which code to use. Both have the same 2025 Medicare rate of $325.41.

How many RVUs is CPT code 99476 worth?

CPT code 99476 has a total of 10.06 RVUs for 2025, consisting of 6.75 work RVUs, 2.73 practice expense RVUs (both facility and non-facility), and 0.58 malpractice RVUs. This places it among the higher-value E/M codes due to the intensity and complexity of pediatric critical care.