Pediatric coding and billing involves billing for services provided to infants and children up till the age of 21. Most pediatric patients are covered by Medicaid but outpatient pediatrics Medicaid billing can be challenging. The recent ICD-10 implementation has also affected Pediatric coding. That’s not all, further CPT® pediatric coding updates are just around the corner, ready to spring into action in CY2016.
Evaluation and Management Services Billing under Pediatrics
In E/M billing, pediatric visits last longer than other specialties because the patients are children who may not understand detailed and complicated instructions. Caregivers are usually parents, mostly young and inexperienced and anxious about their children’s health. Pediatricians therefore, often find themselves spending a long time advising and counselling and coordinating care, resulting in higher levels of E/M service. For pediatricians, if they spent 25 minutes with a patient, the visit can be documented as a 99214 visit, if the pediatrician can detail the discussion held with the patient or the caregiver. To code for a 99214 visit, CMS requires accurate documentation of two of three essential elements, mainly, components history, physical exam and medical decision making.
99214 – CMS Requirements for Documentation
Reporting the history includes the chief complaint, history of the present illness (HPI), the past medical, family and social history and the review of systems. Documentation of the physical examination requires the examination of 5-7 systems including the vital signs of the patient. Medical decision making is the most complex and challenging thing to document. CMS recognizes low complexity, moderate complexity, and high complexity MDM. The complexity of establishing a diagnosis is done by measuring certain parameters; the nature of the presenting problem, the data reviewed, the risk of significant complications, morbidity and mortality associated with the patient’s presenting problem, the diagnostic procedure and possible management options.
CPT code Updates
The following are the CPT updates coming in 2017
| Status | Code | Descriptor |
| New | 36456 | Partial exchange transfusion, blood, plasma or crystalloid necessitating the skill of a physician or other qualified health care professional, newborn |
| Revised | 90655 | Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for intramuscular use |
| Revised | 90656 | Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use |
| Revised | 90657 | Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use |
| Revised | 90658 | Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use |
| Revised | 90661 | Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use |
| Revised | 90685 | Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for intramuscular use |
| Revised | 90686 | Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use |
| Revised | 90687 | Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL dosage, for intramuscular use |
| Revised | 90688 | Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage, for intramuscular use |
| Revised | 90644 | Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus influenzae type b vaccine (Hib-MenCY), 4 dose schedule, when administered to children 6 weeks-18 months of age, for intramuscular use |
| Revised | 90698 | Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae type b, and inactivated poliovirus vaccine, (DTaP-IPV/Hib), for intramuscular use |
| Revised | 90734 | Meningococcal conjugate vaccine, serogroups A, C, Y and W-135, quadrivalent (MCV4 or MenACWY), for intramuscular use |
| Revised | 90686 | Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use |
For a more on 2017 CPT and procedure codes updates attend our online coding event Virtual Boot Camp This session will review all of the CPT codes and procedure codes that should be used in Pediatrics but typically don’t get billed correctly, as well as understand the use of modifiers when billing procedures.
