Pediatrics is the branch of medicine that involves the medical care of infants, children, and adolescents. The American Academy of Pediatrics recommends people be under pediatric care up to the age of 21. A medical doctor who specializes in this area is known as a pediatrician.

Common Pediatrics Billing issues:

The introduction of new ICD – 10 codes that are introduced for vaccines by HIPPA. There are lots of newborns and the vaccinations that can be approved by the medical insurance companies only if the ICD – 10 codes are properly used

The other kinds of possible errors when a medical claim is submitted for the newborn baby are –

  • Wrong codes – it is possible for the billers to file a claim with wrong codes, for example, a medical biller will enter the code for anesthesia instead of diarrhea which can cause obvious hurdles to the doctor as well as the patient.
  • Wrong details – if the name of the patient is entered incorrectly or with spelling mistakes, this will affect the doctors as the claim form will be rejected.
  • One of the most expensive errors – Many pediatric practices are unaware that they can bill for many services which they believe to be ‘specialty services. For example, a common childhood injury is Nursemaid’s Elbow. This is an elbow dislocation. Many pediatricians do not realize that they can bill for this, but they think it is an orthopedic surgery code. This procedure is not invasive but rather an orthopedic manipulation and therefore billable by the pediatricians.
  • Another possible challenge faced by the Pediatricians is lack of EHR interoperability. Many doctors are still not able to transfer all the information he needs to share.

Modifier usage:

Modifier 25 (significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service) is the most important modifier for pediatricians in Current Procedural Terminology (CPT®). It creates the opportunity to capture physician work done when separate E/M services are provided at the time of another E/M visit or procedural service. This allows for more efficient use of your time and may save the patient another visit. However, use of this modifier has been associated with frustration because many payers, including Medicaid, do not recognize it. The landscape is now changing, with many major payers facing the pressure of successful class-action lawsuits requiring them to recognize and follow CPT guidelines, including modifier 25.

Preventive Medicine Service Codes ❖ Services included under these codes include measurements (length/height, head circumference, weight, body mass index, blood pressure) and age- and gender-appropriate examination and history (initial or interval). Pediatric Preventive Medicine Services New Patient Established Patient Age –18 y 99385 >–18 y

If an illness or abnormality is discovered, or a pre-existing 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 key components of a problem-oriented evaluation and management (E/M) service (history, physical examination, medical decision-making, counseling/care coordination, or a combination of those), the appropriate office or other outpatient service code should be reported in addition to the preventive medicine service code. Append modifier 25 to the office or other outpatient service code. 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.