Billing code 99475: Pediatric critical careMedicare rate & RVUs

Medicare pays $473.96 for 99475 nationally in a facility.

Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.

What 99475 covers

This code covers the initial inpatient day of intensive physician care for a critically ill or injured child who is 2 through 5 years old. Typical situations include severe respiratory failure, septic shock, or major trauma requiring close assessment and active management of threatened vital functions. A pediatric intensivist or another physician providing critical care may report it in a pediatric intensive care unit or another inpatient setting when the child’s condition calls for that level of care; the unit’s name alone does not establish the service.

Select the code based on the child’s age and whether the service is the initial or a subsequent critical care day. The record should establish the child’s age, acute severity, critical care decisions and interventions, and the physician’s ongoing management of life-threatening instability. Report 99476 for a subsequent critical care day in this age group. CMS assigns work, practice-expense, and malpractice values to 99475 in the Physician Fee Schedule; the code’s payment is based on those schedule values and applicable claim circumstances.

This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.

Where 99475 pays more and less

The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.

109 of 109 payment localities

99475 rates by state

Office rate range in each state. Select a state to see its payment localities.

How the 99475 rate is calculated

Each of 99475’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.

Payment rules and modifiers for 99475

99475 has no global surgery period, no multiple-procedure, bilateral or assistant-at-surgery adjustment, and no professional/technical split. What changes the payment is where the service happens: the place of service on the claim decides whether Medicare pays the office or the facility rate.

99475 compared with similar codes

How to choose

99476Pediatric critical care

Both codes cover inpatient pediatric critical care for children aged 2 through 5. Choose 99475 for the initial day and 99476 for a subsequent day.

99471Pediatric critical care

99471 covers initial inpatient pediatric critical care for a younger age group; 99475 is for children aged 2 through 5.

99291Critical care

99475 is an age-specific daily code for inpatient pediatric critical care. Code 99291 reports qualifying time-based critical care for patients outside this age-specific range.

Codes related to 99475

Related codes aren’t interchangeable: bill the code that matches the service performed.

Where these rates come from

FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.

CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027

Open CMS sourceHow we calculate rates