Author: Anusha Seal, Medical Coding Specialist
The utilization of Pediatric Current Procedural Terminology (CPT) codes is essential for the precise billing of healthcare services catering to individuals from birth to 16 years old. These codes, officially recognized by the FDA, constitute a distinct subset within the broader CPT code system primarily focused on adult medical conditions. Accurate labeling of each pediatric service is imperative for medical providers to facilitate proper reimbursement from insurance providers. Pediatric CPT codes play a crucial role in streamlining claim processing, ensuring billing accuracy, and minimizing the likelihood of insurance claim denials. Despite facing financial challenges, pediatricians prioritize specialized care, exemplified by their emphasis on services such as vaccinations, underscoring their unwavering dedication to children’s health and the overall well-being of the community.
Some of the most frequently used CPT codes in pediatrics are listed below:
E/M Codes for Evaluation and Management
Visits to the doctor’s office, a specialist’s office, or the emergency room can all be described with E/M codes. These codes are determined by the healthcare professional’s level of service provided to their patients. The most prevalent pediatric E/M codes are:
99213 – Appointment-based Level 3 Care for Existing (established) Patients
A moderate level of medical decision-making is required for this code, which describes an established patient’s office visit. Follow-up appointments that are not urgent should use this code.
99214 – Level 4 Visit by an Existing Patient to an Office
This code describes established patient office visits requiring significant medical judgment. This is the go-to billing code for doctor’s appointments that address several severe health concerns.
99203 – Level 3 First Consultation for a New Patient
This code describes a new patient office visit requiring some medical judgment.
99204 – Level 4 Initial patient office visit
This code describes a new patient office visit that needs more complex medical decision-making.
Services for Preventative Medicine
Services in preventive medicine aim to improve and safeguard people’s health. Most pediatricians rely on the following preventive medicine services:
99381 – Check-up for new patients younger than a year
Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient.
99382 – Primary care check-ups for new patients aged 1–4 years
Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient.
99383 – Primary care check-ups for children aged 5-11 years old
Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient.
99384 – Primary care check-ups for children aged 12-17years old
Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient.
99391 – Regular check-ups for established patients, age less than 1 year
Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient.
99392 – Existing patient wellness check-ups, age 1–4 years
Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient.
99393 – Established patient, age 5-11-year, for preventative care
Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient.
Administrative codes for immunizations
Codes for the administration of immunizations or vaccines are used to characterize the process. Pediatricians most commonly use the following vaccination administration codes:
90460 – Counseling and immunizations for kids up to age 18
Immunization administration through 18 years of age via any route of administration, with counseling by a physician or other qualified health care professional; first or only component of each vaccine or toxoid administered.
90461 – Administration of vaccines without advice till the age of 18
Each additional vaccine/toxoid component administered (list separately in addition to code for primary procedure)
Medical Laboratory and Diagnosis Codes
Codes in the laboratory and medical fields describe various diagnostic procedures and laboratory testing. The most used laboratory and diagnostic codes in pediatrics are as follows:
81002 – Automated urinalysis that does not require a microscope
This code indicates a urinalysis that does not require a microscope.
87880 – The results of a Strep A test
This code is assigned to a quick strep test to identify if Group A Streptococcus bacteria are present in a patient’s throat.
85025 – Blood count, complete (CBC)
Hemoglobin levels, platelet counts, and the number of red and white blood cells are all described by this code.
Other Frequent Codes
In addition to the codes mentioned above, pediatricians also use a variety of others. For example:
99211 – Level 1 established patient visits to the doctor’s office
This code is used to identify an office visit for an established patient that involves minimal medical decision-making.
99401 – Individualized risk factor reduction and preventative counseling, 15 minutes
Individual preventive counseling sessions of 15 minutes duration are described using this code.
99402 – Risk factor reduction and preventative counseling, 30 minutes for each person.
Individual sessions of preventative counseling lasting 30 minutes each are described using this code.
Conclusion
Proper coding in pediatric care ensures that services rendered are appropriately documented and billed, reducing the risk of claim denials, billing errors, and revenue loss. It also facilitates timely reimbursement, thereby enhancing the overall financial performance of the practice.
Globe Centrix offers comprehensive solutions to streamline pediatric practices’ coding processes. Our advanced technology and expertise in healthcare coding and billing can assist in optimizing coding accuracy, reducing errors, and improving overall revenue cycle management. Through our tailored solutions, Globe Centrix can help pediatric practices navigate the complexities of coding, ensuring compliance, maximizing reimbursements, and ultimately contributing to the financial success and efficiency of the practice.