Introduction

Pediatrics is the branch of medicine that diagnoses and treats diseases concerning to infants, children, and adolescents. According to the American Academy of Pediatrics, pediatric care focuses obviously on patients up to the age of 21. Pediatric medical billing and coding have some crucial aspects that make it distinct from other medical specialties. These crucial aspects include unique requirements for pediatric medical billing, vaccination management, maintaining records for vaccinations, and many others. Accurate pediatric medical coding for vaccination records is essential to ensure proper reimbursements for the services related to Pediatrics.

Furthermore, the field of pediatrics can also be demanding because of complex modifiers and bundling requirements. Apart from that, in-house staff also faces more significant challenges than other specialties. For that reason, it becomes compulsory for them to deal with the complexities of working with children and strictly follow the pediatric medical billing and coding regulations.

In order to deal with the complexities, continuous reforms are being introduced in the medical billing and coding requirements, specifically in the discipline of Pediatric Treatment. As per reforms, healthcare providers must be more concerned regarding Children’s susceptibility to contagious diseases and restlessness. They are also required to develop a comprehensive system to ensure minimum waiting time for treatment. They must be able to manage tasks like vaccination records, age-related documents, and compliance policies of the Government.

Pediatric Medical Billing and Coding

The healthcare industry has been evolving and making substantial changes in medical practices, technology, and regulations. One crucial aspect that has put great impact on the medical industry is ‘accurate pediatric medical billing and coding’. This is considered crucial because it ensures that healthcare providers are receiving fair compensation for their services. It also guarantees high-quality patient care. Current Procedural Terminology (CPT) codes play a crucial role in this process. They provide a standardized language for reporting medical procedures and services.

Understanding CPT Codes For Pediatric

CPT codes are developed and maintained by the American Medical Association (AMA). These codes help healthcare providers to communicate effectively with insurance companies and other stakeholders. This is efficient for ensuring that services are appropriately documented and billed. It has been observed that each year, the AMA updates the CPT code set to reflect changes in medical practices. The changes in the codes also influence the technology and regulatory requirements. This ensures that the codes remain current and accurate for healthcare providers across various specialities.

The 2023 CPT code updates took effect on January 1, 2023. These updates bring changes and additions to the existing code set. It is impacting various medical specialities, including pediatrics. For that reason, in the modern and evolving medical care industry, it has become crucial for healthcare providers to stay informed regarding these changes. It helps in accurate pediatric medical billing and coding practices.

Reforms in Pediatric Medical Billing and Coding Year 2023

The 2023 CPT code updates include several changes that are relevant to pediatric care. These changes affect the document and bill practices of pediatricians for their provided care. Here are key updates in the pediatric medical billing and coding updates for the year 2023.

 Updates in Hospital Observation Services

Pediatric medical Billing and coding regulations concerning the Hospital Observation Service are updated in the year 2023. Hospital observation care involves monitoring the patients for a specific period. This period is often determined based on the fact: if the patient requires admission or can be discharged safely. The CPT codes have changed to streamline and clarify the medical coding process. The extended observation period has helped patients to get high-quality medical care.

Updates in Observation Care Discharge Services

The previous code used for observation care discharge service was 99217. However, this code has been deleted in the latest Pediatric medical billing and coding Reforms. The healthcare providers can now use the code 99328 or 99239 for observation care discharge service. These changes have benefited patients to obtain extended care facilities until discharged.

Updates in Observation Care of New or Established Patients

The previous codes for observation care of new or established patients were 99218, 99219, and 99220. However, these codes have been deleted in the ongoing pediatric medical billing and coding reforms. Healthcare providers now use 99221, 99222, or 99223 based on the complexity of the service.

Updates in Subsequent Observation Care

The codes 99224, 99225, and 99226 were used for subsequent observation. However these codes have been deleted in the latest Pediatric medical billing and coding Reforms. The healthcare providers are now using codes 99231, 99232, or 99233, depending on the level of care required.

Hospital Inpatient and Observation Care Services

A new section in the latest Pediatric medical billing and coding Reform has combined the hospital inpatient and observation care services into a single category. This change simplifies medical coding for such services. It will help healthcare providers to select the appropriate codes for these combined healthcare facilities.

Initial Hospital Inpatient or Observation Care

In the latest Pediatric medical billing and coding Reforms, the Codes 99221, 99222, and 99223 will be used to report the first hospital inpatient or observation status encounter with the patient. An initial service may be notified when the patient has not received any professional services from the physician.

The initial service may also be reported if the patient has not received treatment from a qualified healthcare professional of the exact same speciality and sub speciality. However, such specialists must be from the same group practice during the stay. For instance, the advanced practice nurses and physician assistants working with physicians are considered to be in the same speciality and sub speciality as the physician.

Subsequent Hospital Inpatient or Observation Care

In the latest Pediatric medical billing and coding Reforms, the Codes 99231, 99232, and 99233 are used for subsequent hospital inpatients. The time spent on the date of the initial treatment is a key factor in selecting one of these appropriate codes. These codes have been introduced for facilitating healthcare professionals for providing care to subsequent Hospital inpatient and observation care.

Hospital Inpatient or Observation Care Service

This category includes medical codes used to report hospital inpatient or observation care services provided to patients admitted and discharged on the same date of service.

In the latest Pediatric medical billing and coding Reforms, 99234, 99235, and 99236 Codes require two or more encounters on the same date, with one being an initial admission encounter and the other a discharge encounter. On the other hand, for patients admitted and discharged during the same encounter, it is not required to use the 99238 or 99239 code in conjunction with the admission and discharge services.

Hospital Inpatient or Observation Discharge Services

The latest Pediatric medical billing and coding Reforms have directed healthcare professionals to report the total duration of time on the date of the encounter. This includes the final examination of the patient, discussions regarding the hospital stay, instructions for continuing care, and preparation of discharge records and referrals. In the ongoing reforms, Codes 99238 and 99239 are used by the physician for discharge services. On the other hand, the services by other healthcare professionals may be reported with codes 99231, 99232, and 99233.

Medical Coding Updates in Consultations

Consultations include evaluation and management services provided at the request of another physician. Qualified healthcare professionals are considered the appropriate source to recommend care for a specific condition or problem. As per new updates, a consultant may initiate diagnostic and therapeutic services at the same or subsequent visit.

Outpatient Consultations New or Established Patient

Medical codes for office or other outpatient consultations have been updated in the year 2023. The previous code was 99241. However, it has been deleted in the latest Pediatric medical billing and coding Reforms. Providers can now use Code 99242 to report these services. Apart from that, new medical codes such as: 99242, 99243, 99244, and 99245 have been introduced each reflecting different levels of complexity and time requirements.

Inpatient or Observation Consultations New or Established Patient

In the latest Pediatric medical billing and coding Reforms, 99252, 99253, 99254, and 99255 medical Codes are used to report the qualified healthcare consultations that are provided to various categories of patients. These categories specifically include hospital inpatients, observation-level patients, nursing facility residents, or patients in a partial hospital setting.

As per the latest Pediatric medical billing and coding Reforms, one can report only one consultation per admission. If there are additional consultation services needed during the same admission, he should use subsequent inpatient or observation hospital care medical codes 99231/99233 or subsequent nursing facility care codes 99307/99310 to document and bill for those services.

Emergency Department Services New or Established Patient:

Medical codes for emergency department services have been updated with different levels of complexity. These specifically include the addition of the following medical codes:  99281, 99282, 99283, 99284, and 99285.

Home or Residence Services

Medical codes for home or residence services have been revised in the latest Pediatric medical billing and coding Reforms. The new medical codes 99341-99350 have replaced the old medical codes.

Updates in Prolonged Services Medical Codes

Prolonged service medical codes have seen significant changes in the latest Pediatric medical billing and coding Reforms. These medical codes are used to report services that require additional time beyond the typical service duration are as follow:

• In the latest Pediatric medical billing and coding Reforms, medical codes 99354 and 99355 have been deleted. Medical code 99417 will now be used for prolonged evaluation and management services on the date of outpatient service, home or residence service, or cognitive assessment and care plan.
• Similarly, Medical codes 99356 and 99357 have also been deleted under the latest pediatric medical billing and coding reforms. For now, Healthcare professionals will be using medical codes 99358 and 99359 for prolonged service provided on a date other than the date of a face-to-face evaluation and management encounter with the patient.
• As per updated standards, Medical codes 99417 and 99418 will be used to report prolonged total time provided by the physician or qualified healthcare professional.

Prolonged total time is defined as time that exceeds the time required to report the highest-level primary service by 15 minutes.

Do not report these medical codes for time increments of less than 15 minutes.

Surgery: Integumentary System

• Medical code 15851 for the removal of sutures or staples under anaesthesia has been updated with specific instructions.
• Medical code 15853 for the removal of sutures and staples not requiring anaesthesia has been introduced Healthcare will be used in the latest Pediatric medical billing and coding Reforms.

Pathology and Laboratory

A new medical code, 87913, has also been introduced for infectious agent detection by nucleic acid (DNA or RNA). This is specifically related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Ensure MBS Expertise in Pediatrics

At Ensure MBS, their client base spans across the globe. This will include a diverse array of hospitals, physician practices (including pediatrics), and medical billing companies. Our coders possess proficiency in ICD-9/10, CPT, and HCPCS medical coding guidelines provided by CMS and AMA. Ensure MBS is well complying with the standards and directions of the American Academy of Professional Coders (AAPC). It is helping the firm in bringing a decade of experience to the field of pediatric medical billing and coding.

Regardless of the size of a pediatric practice, outsourcing medical billing and coding needs to an experienced provider like Ensure MBS can play a crucial role in saving and improving the revenue cycle. Ensure MBS offers a range of services, including; prior authorisations, claim submission, accounts receivable management, denial handling, and credentialing. Our team of pediatric medical billing specialists is well-equipped to establish a revenue cycle without leaks.

Conclusion

By and large, it can be concluded that in the year 2023, the reforms in pediatric medical billing and coding have played a crucial role. These reforms aim to ensure that children receive the best possible healthcare. Pediatric care is unique, and these changes are designed to make the pediatric medical billing and coding process more accurate and efficient. The updates in Current Procedural Terminology (CPT) codes are a significant part of these reforms. These medical codes help healthcare providers communicate with insurance companies.

The latest Pediatric medical billing and coding Reforms ensure that services are documented and medical billed correctly. Under these reforms, it has become imperative for healthcare providers to stay informed regarding these changes. This ensures fair compensation for their services and maintains high-quality patient care records. These reforms also address various aspects of pediatric care. These include hospital observation services, discharge services, consultations, and more. Outsourcing medical billing and coding to experienced providers like Ensure MBS can benefit pediatric practices. Such organisation’s expertise is well-versed in complying with the guidelines provided by CMS and AMA.

Accurate medical coding is about more than just getting paid correctly. It is also about maintaining the integrity of patient care records. Pediatricians play a crucial role in children’s health, and accurate medical coding ensures that their efforts are appropriately compensated. In this ever-evolving healthcare landscape, staying informed and adapting to changes in medical billing and coding is essential. Healthcare providers should refer to the 2023 CPT code book and utilize resources from their professional organizations to deal with these updates successfully.

Frequently Asked Questions (FAQ)

What is Pediatric Medical Billing and Coding?

Pediatric Medical Billing and Coding is the process of translating medical services and procedures provided to infants, children, and adolescents into standardized codes for medical billing and insurance purposes.

What makes pediatrics different from other Healthcare services?

Pediatrics has unique requirements for medical billing because it focuses on age-specific treatments, vaccinations, and complex modifier and bundling rules. These require specialized medical coding and billing practices.

What are key Pediatric Medical Billing and Coding reforms?

The key pediatric medical billing and coding reforms are the 2023 CPT code updates include changes in areas like hospital observation services, discharge services, consultations, and more. These changes affect how pediatricians document and medical bill for their services.

What is the importance of pediatric medical coding?

Accurate medical coding plays a vital role in ensuring that healthcare providers receive proper compensation for the services they provide. It involves assigning the correct codes to medical procedures and services rendered, which is used by insurance companies and government programs to determine payment levels. Accurate medical coding also helps maintain the integrity of patient care records, which is important for delivering high-quality pediatric care. By ensuring that medical coding is done correctly, healthcare providers can avoid financial penalties and maintain compliance with regulatory requirements. Additionally, accurate medical coding helps healthcare providers track patient outcomes and identify areas for improvement in their care processes.

How can outsource medical billing and coding benefit pediatric practices?

Pediatric practices can greatly benefit from outsourcing their medical billing and coding to experienced providers like Ensure MBS. By doing so, they can save significant costs while also ensuring accurate and efficient medical coding practices. Outsourcing pediatric medical billing and coding also allows pediatric practices to focus on their core competency of providing quality healthcare to their patients.

Ensure MBS has a team of experts who are well-versed in the latest medical coding practices, ensuring that claims are submitted accurately and in a timely manner. This not only reduces the risk of claim denials, but it also helps practices receive reimbursements faster.

Moreover, Ensure MBS uses advanced technologies that streamline the pediatric medical billing process, making it more efficient and transparent. This allows practices to gain better visibility into their revenue cycle and make informed decisions.

Overall, outsourcing pediatric medical billing and coding to Ensure MBS can help pediatric practices improve their financial performance, reduce administrative burden, and enhance patient satisfaction.

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