Demystifying Pediatric Coding

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.

ICD-10 Coding for Pediatrics

Pediatrics is affected by CPT® codes, HPCS codes and ICD-10 codes. Under ICD-10 codes, it’s important to use codes at the highest level of specificity, although this is the only specialty for which CMS made the allowance of accepting non-specific codes as long as they are close to the family wanted for a period of 1 year. As appropriate, coders in pediatric coding can use more than one diagnosis if using high levels of care or critical care as long as they are pertinent to the visit for that particular date. Coders should also use different diagnosis codes for a visit and for a procedure. Under ICD-10 there are Z codes which can be for information only and can be payable. On the other hand, V, W, X, Y codes have been used when there is an injury, poisoning and certain other consequences of external causes. These codes describe how and where something happened and are found under chapter 20 in ICD-10.

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.

To make things more complex, there are new CPT® coding changes expected in 2016. Coders in the pediatrics specialty need to be aware of the updated classification for vaccine/ toxoid administration along with latest codes that recognize complex care coordination of patients with episodic health and chronic continuous conditions. They must also be aware of code changes and transitional care management services to revised E/M coding guidelines. For greater clarity on coding for Pediatrics, check out these audioconference on CPT® Pediatric Coding Changes from expert speaker Donelle Holle.

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