Basics of Coding in Pediatrics Medical Billing
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Pediatrics medical billing focuses on services provided to young patients, with complexities such as state-specific Medicaid programs and unique coding requirements. Pediatricians can optimize billing by accurately documenting evaluation and management visits, particularly for codes like 99214, which demand detailed patient history and physical exam components. Reliable medical billing services can help navigate the intricacies of pediatric billing, ensuring timely and accurate reimbursements, and enhancing overall operational efficiency.
Basics of Coding in Pediatrics Medical Billing
- 2. Pediatrics Medical Billing involves billing for healthcare services provided to infants, children and adolescents. Medicare compliancy does not apply to pediatrics, but there are other complexities to look out for. The lion’s share of patients in pediatric practices is covered by Medicaid, with each state having its own unique Medicaid program. Outpatient pediatrics Medicaid billing can be really challenging. In E/M billing, pediatricians have a definite advantage over other specialists. A scheduled pediatric visit can last for a very long time, according to CPT. This is because the patients here are children who cannot understand detailed and complicated instructions. Moreover, the caregivers who are mostly young are by and large inexperienced and anxious about their kids’ health. The pediatrician can therefore spend a long time in advice and counseling or coordinating care, which in turn will result in billing a higher level E/M service. Evaluation and Management Billing for Pediatricians When a pediatrician documents that he/she spent 25 minutes with a patient, of which 13 or more minutes were spent on counseling and then detail your discussion, that visit qualifies as a 99214 visit. Pediatricians must time their visits accurately. Two 99214 visits per hour are possible with time-based billing, whereas there are no such time limitations when using the documentation approach to bill a 99214 visit. www.outsourcestrategies.com
- 3. Evaluation and Management Codes Pediatricians Bill for are: 99213 Low Complexity, easy/brief problems CC, HPI (1-3 elements), ROS 1, PEX 2-4 elements, low MDM, 15mins Examples: URI, UTI, fever, pharyngitis, influenza Moderate Extended HPI (4 or more), extended ROS (2-9), 1 PFSH, PEX 5-7, moderate MDM, time 25min Examples: chronic headaches, abdominal pain, AOM, fatigue, fever without a source, behavioral problems, ADHD f/u 99214 99215 Comprehensive Extended HPI, complete ROS (10+: "all other systems reviewed and negative"+pertinent elements that are not used in HPI for billing), 2 PFSH, PEX 8+, MDM high, time 40mins Examples: Headache with vomiting, behavior problems, ADHD initial evaluation, diabetes with influenza, anorexia. www.outsourcestrategies.com
- 4. A 99214 code is reimbursed at a higher rate than a 99213 code. Physicians need to understand the basics to correctly code and document a 99214 office visit and get reimbursed for it. The Correct Documentation Style Correct documentation for an office visit should contain the components history, physical exam and medical decision making. To code for a 99214 visit, CMS requires accurate documentation of two of these three elements. To report the history, include the chief complaint, history of the present illness (HPI), the past medical, family, and social history (PFSH) and the review of systems (ROS). The HPI should include a minimum of 4 of the descriptive elements of the presenting problem. For e.g. if the presenting problem is ear pain, you have to document the location (right ear), quality (stinging or burning), duration ( say, 4 days), timing (constant or sporadic) and severity (8/10 on the pain scale). Report one of 3 elements for PFSH that is pertinent to the presenting problems. For e.g. this could be a list of medications, a statement of drug allergies or exposure to ill persons. Two or more relevant elements of ROS should be documented to satisfy the history component of the 99214 visit. To document the physical exam component of a 99214 visit, examination of 5 – 7 systems including the vital signs of the patient would be sufficient. Determining medical decision making (MDM) is the most challenging piece of coding an office visit. The types of MDM that CMS recognizes are straightforward, low complexity, moderate complexity, and high complexity. The complexity of establishing a diagnosis and/or deciding on a management option is done by measuring: -The nature of the presenting problem -Data reviewed -The risk of significant complications, morbidity and/or mortality associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options. www.outsourcestrategies.com
- 5. Some Common Codes in Pediatrics CPT Codes HPCS Codes ICD 9Codes www.outsourcestrategies.com
- 6. CPT Codes 81002: urine dipstick 90722: injection/antibiotic/synagis/Ig 95165: injuction/allergy shot 53670: Urine Cath 54450: Foreskin lysis 17250: Cord Cauterization HPCS Codes J0170: epinephrine J0696: cetriaxone 250mg J7510: orapred J7611: albuterol for inhalation in office 1mg dose ICD 9 Codes 783.21: weight loss 765.1: prematurity 786.07: wheezing (if no asthma exaccerbation) 278.02: overweight 783.1: abnormal weight gain 786.09: snoring 783.5: polydipsia 272.1: hypertiglyceridemia 780.71: chronic fatigue syndrome www.outsourcestrategies.com 36415/6: venipuncture/fingerstick
- 7. Modifiers need to be correctly used with a code when necessary: -25: separately identifiable E/M services by same physician on the same service date as a procedure (and EM and a procedure done on the same day) -51: multiple procedures by the same physician on the same date of service for the same identifiable E/M -59: separate "distinct" procedure -57: surgery code used for removing foreign body, reducing an elbow Medical Billing Services Can Be Supportive There are specific billing requirements characteristic of the pediatric specialty such as billing for vaccines. Vaccines must be billed and followed up opportunely to ensure accurate reimbursement. Providers must make sure that the right NDC number and diagnosis code are used, apart from ensuring that the payer rues are followed to the minutest detail. Another consideration is ICD- 10 billing. This requires familiarization with the ICD-10 codes which are more complex and comprehensive. In this context, reliable medical billing services can be really supportive. Medical Billing Services Can Be Supportive There are specific billing requirements characteristic of the pediatric specialty such as billing for vaccines. Vaccines must be billed and followed up opportunely to ensure accurate reimbursement. Providers must make sure that the right NDC number and diagnosis code are used, apart from ensuring that the payer rues are followed to the minutest detail. Another consideration is ICD-10 billing. This requires familiarization with the ICD-10 codes which are more complex and comprehensive. In this context, reliable medical billing services can be really supportive. www.outsourcestrategies.com
- 8. Comprehensive Medical Billing Services www.outsourcestrategies.com General Pediatrics Pediatric Endocrinology Pediatric Cardiology Nutrition Services Pediatric Infectious Diseases Pediatric Neurology Pediatric Oncology Pediatric Gastroenterology Pediatric Pulmonology Pediatric Nephrology Clinical Genetics Behavioral Psychology Child Life Program
- 9. Why Outsourcing Pediatrics Medical Billing Is Practical? Professional medical coders and billers will have adequate knowledge in the basics of pediatrics medical billing and ensure timely and accurate medical coding and billing. This will allow you to invest more time on providing patient care and staying competitive in the industry. Apart from that, you could enjoy a lot of benefits such as the following. Speedy and maximum reimbursement Avoid coding mistakes and delays Minimize payroll and operational expenses The cost of telephone and postage expenses is reduced Efficient follow-up on denied claims Improved office efficiency Cut down staffing issues and training time One-time claim submission Maximize patient and physician satisfaction Reduce paperwork and the burden of handling tasks in-house Enhanced cash flow and improved collections Generate and submit claims through electronic means Increase overall revenue www.outsourcestrategies.com