Pediatric Billing Guidelines

Specializing in children’s health is a rewarding profession itself, but it must also be financially compensated. Following the latest pediatric billing guidelines ensures the financial stability of your practice, efficient revenue management, and compliance with the latest laws and regulations.

With proper adherence, you can mitigate the risk of audits financial penalties, and legal repercussions while promoting operational efficiency. As experts in revenue cycle management, medical coding, and billing, we created this guide to introduce you to strategies for effective pediatric billing that will lead to proper reimbursement.

Understanding Pediatric Billing Guidelines

Medical coding and billing is an ever-changing field that medical billers must keep up with. Following pediatric billing guidelines is essential for staying compliant and ensuring proper reimbursement for the services you provide.

The pediatric billing guidelines include a wide set of rules and practices every pediatric healthcare provider must follow. They are focused on ensuring pediatricians properly document the visits and treatments they provide, and provide guidance for efficient claim submission. It will also help the financial status of the practice by accurately posting payments in the system.

Although it might seem simple to assign accurate codes to specific medical procedures the patient has had, it is much more complicated than that. Pediatric coding and billing are complex fields with various challenges, such as navigating the complex coding system for a wide range of services.

Pediatric medical billers commonly have to deal with:

• Multiple payers
• Claims for vaccines
• Reimbursement for preventive services
• Well-child visits
• Keeping growth charts and doing milestone assessments
• Handling treatments for multiple siblings under one family insurance account
• Frequent coverage changes due to aging out of eligibility, divorce or parents changing jobs

Documentation Requirements

As with every other billing process, the reimbursement process for pediatric services requires accurate and up-to-date data and proper documentation. Regarding data, it is essential for your healthcare facility to gather all data about the patient and their insurance, typically by filling out a patient information form and checking their insurance card.

When it comes to documentation, the list can be extensive, but the most important ones are:

• Medical history
• Parental consent and treatment authorization
• Progress notes
• Lab results or diagnostic reports
• Certificates of medical necessity
• Discharge summaries
• Operative reports

Coding Excellence

Accurate coding is required for effective billing and timely reimbursement and for compliance with industry standards. The correct code assignment increases the chances of seamless payment for the services provided to the children.

The two main sets of medical codes used in pediatrics are Current Procedural Terminology codes and International Classification of Diseases codes. The CPT codes are used for the services rendered, while the ICD codes are specifically for diagnoses.

CPT codes for pediatrics

The CPT codes for preventive care are grouped according to the type and age of the pediatric patient. They range from 99381 to 99385 and 99391 to 99395. The first group is for new patients, while the codes 99391 to 99395 are used for established preventive care. 

Other commonly used codes indicate:

• The duration of the counseling session,
• Time for chronic care management,
• Tune required for high-risk disease etc.

ICD codes for pediatrics

On the other hand, ICD codes are used for the diagnosis in primary, secondary and tertiary care. The ICD codes for pediatrics are divided according to the type of diagnosis. To illustrate, the ICD-10-CM codes from 789.00 to 789.09 are for abdominal pain, the ICD-10-CM codes from 250.00 to 250.03 are for diabetes mellitus etc.

Just like the codes, the use of modifiers is extremely important. Modifiers reveal additional details about the procedure or service that the pediatrician has provided.

Verification of Insurance Benefits

Children are a special group of patients for healthcare insurance. Typically, they are covered under their parent’s plan until they turn 26. Like all specialties, verifying the insurance coverage of the patient is important and required in pediatric billing.

The insurance verification process confirms the patient’s insurance policy details, including coverage. This will allow your medical billing team to better understand the insurance policy and its limitations. 

As a pediatric practice, you can ensure that the insurance will cover the services before you provide them to the patient. If it doesn’t, you can inform the parents that they need to cover the services and treatments out of their own pockets, eliminating the risk of unpaid claims.

Claim Submission Processes

As a healthcare provider, you have two ways to submit a claim: a paper claim and an electronic claim submission. Nowadays, the most commonly utilized method is electronic submission, as it often has faster processing time and complies with HIPAA regulations.

For timely reimbursement, your practice can utilize some of the following pediatric billing guidelines:

• Use claim notes appropriately
• Ensure clean claims and review each one before submitting
• Submit claims with required attachments promptly and within the insurance company deadlines
• Monitoring claim submission
• Place all primary, secondary, and tertiary carrier information in the proper rows
• Establish healthy communication with insurance providers
• Submit your claims through a clearinghouse

Denial Management Strategies

According to the latest research, around 13% of pediatric claims are denied, which is a little above the average across all healthcare specialists. Consequently, as a pediatric practice, you must have effective denial management strategies.

Generally looking, some of the effective strategies for medical claim denials include:

• Doing insurance verification and pre-authorization prior to providing services
• Implement a claims denial log with denial reasons and categorize denials by type and priority
• Writing strong appeal letters based on facts
• Have a centralized database for patient information
• Ensuring the medical coding and billing team work according to the latest updates and guidelines
• Enhance documentation practices and keep clear records
• Identify healthcare denial trends

Holding on to one strategy is not enough, since there are many reasons why a claim can be denied. Tailoring the strategy according to the specific case is highly recommended.

Outsourcing Solutions by CLICKVISION BPO

Following the pediatric billing guidelines is significant as it increases revenue and ensures compliance with regulations. However, it can be a huge administrative burden for both small pediatric practices and large healthcare facilities with pediatric departments.

Instead of dedicating your time and resources to managing an in-house medical coding and billing department, you can simply outsource your entire revenue cycle management. 

With CLICKVISION BPO, you can have everything you need in one place: coding, billing, charge entry, denial management, and revenue cycle optimization. Our pediatric billing services will increase billing accuracy, minimize coding errors and denial rates, and ensure compliance.

Conclusion

Effective revenue cycle management requires a comprehensive understanding of the pediatric billing guidelines. How successful will your efforts be to get reimbursed for the services you provide, depends on various factors such as documentation collection, coding accuracy, insurance verification, claim submission and denial management.Contact us today if you want to eliminate this administrative burden and have more time and resources to dedicate to your pediatric patients. We will ensure your medical coding and billing process runs smoothly and that you get timely reimbursement for the services you provide.