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Pediatrics Billing and Coding

March 7, 2013

pediatric billing serviceAs usual, it’s been a busy week at M-Scribe Technologies. While we spent much of our time preparing for RAC audits and reviewing National and Local Coverage Determinations, that isn’t all we do. At M-Scribe, we bill for outpatient services with the big picture in mind. While most medical practices deal with the Medicare program, there is one specialty that sees very few, if any, Medicare patients. Accurate pediatrics billing does not usually require Medicare compliance, but it has a host of other issues to watch out for. 

Medicaid covers a large proportion of many pediatrics practices’ patient population. Every state’s Medicaid program is unique. Each has its own requirements. Some people think commercial insurance coverage is confusing. Some people find Medicare difficult and contradictory. Just about everyone agrees that outpatient pediatrics Medicaid billing is the worst. If you are a pediatrics biller, you know what we mean.

One thing that many pediatric healthcare providers do not realize is that they have an advantage over other specialists when it comes to billing evaluation and management (E/M) codes. Other specialists’ patient population are made up of reasonably knowledgeable adults who have at least a layman’s understanding of medicine. A pediatrician’s patient population is made up of children who cannot be entrusted with detailed instructions, and their caregivers are anxious and inexperienced about their child’s health.

Learn More: Advantage of Specialty Specific Medical Billing Experts

According to CPT, a scheduled pediatric appointment can last a long, long time. In some cases, this time spent in advice and counseling or coordinating care can result in a higher level E/M service. As everyone knows, 99215 pays more than 99212. Physicians deserve to be reimbursed for the professional services they perform at a rate that corresponds to that level of service.

When a client called the other day, he asked if ICD-10 billing would impact E/M coding. We discussed various scenarios this physician felt may negatively change how he is reimbursed. He raised issues that he had read on the Internet from unreliable sources. After he expressed his various concerns, he ended by saying, “This whole ICD-10 is just so complicated.” We assured him things will not be that bad, especially if we both work together to prepare ahead.

Pediatrics ICD-10 billing is going to be more complex than ICD-9, but we wouldn’t say it is more complicated. ICD-10-CM is arranged in a logical sequence. Though there are more and longer codes than we are currently used to, each character has a defined meaning in its place. ICD-9 is comfortable because we have been using it for years, but over time it has become a hodgepodge of codes, many of which do not match current medical use.

Of particular note, the 740-759, Congenital Anomalies, series of codes in ICD-9-CM will be described by the ICD-10-CM codes that fall between Q00-Q99, Congenital Malformations, Deformations, and Chromosomal Abnormalities. Just as the terminology of ICD-10 is more precise, so are the codes. The number of codes to describe these conditions is greatly expanded; take the new codes used to describe a diagnosis of a peripheral arteriovenous malformation, something that is unspecified in ICD-9-CM.

When we finished discussing our client’s concerns, he thanked us and we scheduled a convenient time to meet again. As the ICD-10 deadline approaches, we want to help physicians, in every specialty, become comfortable with the new coding system so they can continue to submit clean claims the first time out.


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