CPT 99472
Global XXX ActivePed critical care subsq
CPT 99472 Billing & Documentation Guide
CPT code 99472 (Ped critical care subsq) is classified under E/M with a global period indicator of XXX. The 2026 Medicare Physician Fee Schedule assigns a work RVU of 7.99, a non-facility practice expense RVU of 1.96, and a malpractice RVU of 0.58, a total non-facility RVU of 10.53 and facility RVU of 10.53. With the current conversion factor of $33.4009, the national average non-facility reimbursement is approximately $357.23, though rates vary from $333.09 to $480.71 based on MAC locality and Geographic Practice Cost Indices (GPCIs).
When billing 99472, ensure documentation supports medical necessity and the specific components required for the code's level of service. For E/M codes, document MDM (medical decision-making) elements: problems addressed, data reviewed, and risk. For procedural codes, document the indication, technique, and any complications. Always verify NCCI edits before bundling 99472 with related codes; this code has 10 PTP bundling relationships on file (see table below).
Payment Status & Global Period
Active code (paid under MPFS)
No global period (E/M and other non-procedural services)
MUE Limit (Medically Unlikely Edits)
Submitting more than 1 units of 99472 for the same patient on the same date triggers automatic line denial unless an appropriate modifier and supporting documentation justify the higher quantity.
RVU Breakdown, CPT 99472
| Component | Non-Facility | Facility |
|---|---|---|
| Work RVU | 7.99 | 7.99 |
| Practice Expense RVU | 1.96 | 1.96 |
| Malpractice RVU | 0.58 | 0.58 |
| Total RVU | 10.53 | 10.53 |
| Conversion Factor | $33.4009 | |
2026 Medicare Reimbursement by State, CPT 99472
State-level averages across all MAC localities. Non-facility rates typically apply to office-based services; facility rates apply to hospital outpatient / inpatient.
| State | Non-Facility | Facility | Range (Non-Fac) | Localities |
|---|---|---|---|---|
| California | $364.4 | $364.4 | $353.54 - $401.01 | 29 |
| Florida | $370.27 | $370.27 | $358.58 - $384.02 | 3 |
| Georgia | $352.91 | $352.91 | $348.36 - $357.45 | 2 |
| Illinois | $368.08 | $368.08 | $356.92 - $378.99 | 4 |
| Michigan | $355.62 | $355.62 | $348.52 - $362.71 | 2 |
| North Carolina | $340.33 | $340.33 | $340.33 - $340.33 | 1 |
| New York | $378.9 | $378.9 | $342.68 - $397.77 | 5 |
| Ohio | $346.17 | $346.17 | $346.17 - $346.17 | 1 |
| Pennsylvania | $354.11 | $354.11 | $345.28 - $362.94 | 2 |
| Texas | $350.79 | $350.79 | $344.44 - $360.67 | 8 |
Source: CMS PFSRVU 2026 · Updated 2026-04-01. Full locality-level detail available for all 53 states, contact us for custom reports.
NCCI Bundling Edits, CPT 99472
Procedure-to-procedure (PTP) edits. If you bill any of these codes with 99472 on the same date of service, review the modifier indicator and payer policy before submission.
| Partner Code | Relationship | Modifier Allowed | Rationale |
|---|---|---|---|
| 0188T | Column 1 (primary), can be billed with modifier | No | Misuse of Column Two code with Column One code |
| 0189T | Column 1 (primary), can be billed with modifier | No | Misuse of Column Two code with Column One code |
| 0359T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0360T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0361T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0362T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0362T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0363T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0364T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0365T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
Frequently Asked Questions, CPT 99472
What does CPT code 99472 mean? +
CPT code 99472 represents: Ped critical care subsq. It's in the E/M category with a global period of XXX.
What is the Medicare reimbursement for CPT 99472? +
The 2026 Medicare national average non-facility payment for CPT 99472 is $357.23. Rates range from $333.09 to $480.71 across 53 states depending on MAC locality and GPCIs.
What modifiers can I use with CPT 99472? +
E/M codes commonly use modifier 25 (significant separately identifiable E/M on same day as a procedure), 57 (decision for major surgery), 24 (unrelated E/M during global period), 95 (synchronous audio+video telehealth), 93 (audio-only telehealth), and AI (principal physician of record on admission). Surgical modifiers like 50, 51, 59 do not apply to E/M.
What bundling edits apply to CPT 99472? +
This code has 10 NCCI PTP bundling relationships. See the NCCI Bundling section below for full list.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on May 31, 2026.
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