Read this article for details about the basics of pediatrics medical billing and why outsourcing this billing task can be advantageous for practitioners.

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.
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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.
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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.
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5. Some
Common
Codes in
Pediatrics
CPT Codes
HPCS Codes
ICD 9Codes
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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
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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.
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8. Comprehensive
Medical Billing Services
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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
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