Pediatricians have a lot on their plates. They need to provide excellent care to their young
patients, but they also need to manage the administrative side of their practices. This can be a
daunting task, especially when it comes to
pediatric billing and coding.
Medical billing and coding is a complex and ever-changing field. There are a lot of rules and
regulations that need to be followed, and it can be difficult to keep up with the latest changes.
This is where a pediatric medical billing and coding company can help.
Before jumping to the importance and benefits of delegating the task of pediatric medical billing
and coding to the Revenue Cycle Services Provider let’s check on some
basics.
What is Pediatric Medical Billing and Coding?
Pediatric Medical Billing involves the management of billing and payment processes in pediatric
practices. It encompasses handling payments from insurance companies as reimbursement and directly
from patients as out-of-pocket fees. Essentially, it ensures that fees for pediatric services
rendered are appropriately recorded and receivable.
Pediatric Coding is another crucial aspect, involving the accurate assignment of codes that
correspond to specific medical procedures and diagnoses. These codes are essential for insurance
companies to evaluate and approve claims. When the codes are assigned correctly, pediatric practices
can maximize reimbursement by receiving payment from insurance providers.
The preventive medicine codes are mostly grouped by the type and the age of the pediatric patient –
New vs Established and are age-appropriate CPT codes.
NEW PATIENT
ESTABLISHED PATIENT
99381 – < 1 year
99382 – > 1- 4 years
99383 – 5-11 years
99384 – 12-17 years
99385 – >17 years
99391 – < 1 year
99392 – 1-4 years
99393- 5-11 years
99394 – 12-17 years
99395 – >17 years
PREVENTIVE MEDICINE SERVICE CODES
Services included under these codes include measurements (eg, length/ height, head circumference,
weight, body mass index, blood pressure) and age- and gender-appropriate examination and history
(initial or interval).
▶ Preventive medicine service codes are not time-based; therefore, time spent during the visit is
not relevant in selecting the appropriate preventive medicine service code.
▶ If an illness or abnormality is discovered, or a preexisting problem is addressed, in the process
of performing the preventive medicine service, and if the illness, abnormality, or problem is
significant enough to require additional work to perform the components of a problem-oriented
evaluation and management (E/M) service (ie, using medical decision making or time spent), the
appropriate office or other outpatient service code (99202–99215) should be reported in addition to
the preventive medicine service code. Append modifier 25 to the office or other outpatient service
code (eg, 99392 and 99213 25).
▶ An insignificant or trivial illness, abnormality, or problem encountered in the process of
performing the preventive medicine service should not be separately reported.
▶ The comprehensive nature of the preventive medicine service codes reflects an age- and
gender-appropriate history and physical examination and is not synonymous with the comprehensive
examination required for some other E/M codes (eg, 99204, 99205, 99215).
▶ Immunization products and administration and ancillary studies involving laboratory, radiology,
or other procedures, or screening tests (eg, vision, developmental, hearing) identified with a
specific CPT code, are reported, and paid for separately from the preventive medicine service code.
COUNSELING, RISK FACTOR REDUCTION, AND BEHAVIOR CHANGE INTERVENTION CODES
▶ Used to report services provided for the purpose of promoting health and preventing illness or
injury.
▶ They are distinct from other E/M services that may be reported separately when performed.
However, one exception is you cannot report counseling codes (99401–99404) in addition to preventive
medicine service codes (99381–99385 and 99391–99395).
▶ Counseling will vary with age and address such issues as family dynamics, diet and exercise,
sexual practices, injury prevention, dental health, and diagnostic or laboratory test results
available at the time of the encounter.
▶ Codes are time-based, where the appropriate code is selected according to the approximate time
spent providing the service. Codes may be reported when the midpoint for that time has passed. For
example, once 8 minutes are documented, one may report 99401.
▶ Extent of counseling or risk factor reduction intervention must be documented in the patient
chart to qualify the service based on time.
▶ Counseling or interventions are used for persons without a specific illness for which the
counseling might otherwise be used as part of treatment.
▶ Cannot be reported with patients who have symptoms or established illness.
▶ For counseling individual patients with symptoms or established illness, report an office or
other outpatient service code (99202– 99215) instead.
▶ The diagnosis codes reported for preventive counseling will vary depending on the reason for the
encounter.
▶ Remember that the patient cannot have symptoms or established illness; therefore, the diagnosis
codes reported cannot reflect symptoms or illnesses.
▶ Examples of some possible diagnosis codes include:
Z28.3 Underimmunized status (Code also reason patient is behind, eg, Z28.82 [caregiver refusal])
Z71.3 Dietary surveillance and counseling
Z71.82 Exercise counseling
Z71.84 Encounter for health counseling related to travel
Z71.85 Encounter for immunization safety counseling (Code also if vaccine is not carried out [eg,
Z28.82])
Z71.89 Other specified counseling
Z71.9 Counseling, unspecified Behavior Change Interventions, Individual
OTHER PREVENTIVE MEDICINE SERVICES
Oral Health
CPT Code
99188 Application of topical fluoride varnish by a physician or other qualified health care
professional
ICD-10-CM Codes
121 Routine child health exam with abnormal findings
129 Routine child health exam without abnormal findings
3 Encounter for prophylactic fluoride administration.
841 Risk for dental caries, low
842 Risk for dental caries, moderate
843 Risk for dental caries, high
849 Unspecified risk for dental caries
Pelvic Examination:
▶ Preventive medicine service codes (99381–99385 and 99391–99395) include a pelvic examination as
part of the age- and gender-appropriate examination.
▶ If the patient is having a problem, the physician can report an office or other outpatient E/M
service code (99212–99215) for the visit and attach modifier 25.
▶ Link the appropriate ICD-10-CM code for the well-child or well-adult examination with abnormal
findings (Z00.121 or Z00.01) to the preventive medicine service code.
Why should you employ a professional pediatric medical billing and coding service provider?
It frees up time for pediatricians to focus on patient care. Pediatricians are already busy with
their patients, so outsourcing their billing and coding can free up their time so they can spend
more time with their patients.
It reduces the risk of errors. Medical billing and coding is a complex process, and there is a high
risk of errors if it is not done correctly. Outsourcing to a B2B company can help to reduce the risk
of errors.
It improves efficiency. A B2B company can help to improve the efficiency of the billing and coding
process by using specialized software and processes.
It can save money. Outsourcing can save pediatricians money in the long run by reducing the need for
in-house staff and by avoiding the cost of errors.
If you are a pediatrician, you should consider outsourcing your pediatric medical billing and coding
services to a B2B company. This can help you to free up your time, reduce the risk of errors,
improve efficiency, and save money.
Outsource Pediatric Medical billing and coding to QWay Healthcare:
QWay Healthcare brings to you expert-level professionals to simplify the medical coding and billing
process for over 40+ specialties. You can schedule a free* demo call with us to optimize the revenue
cycle operations of your organizations and streamline the process with an insight-driven approach.
Write to Our Helpdesk.