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Coding accuracy is critical for the financial health of any pediatric practice. All practices experience certain CPT codes that are bundled in with other codes and some level of claim denials. Understanding the most common pediatric coding denials—and how we minimize the impact on Pediatric Practices can help protect the bottom line and improve billing efficiency.
In this article, we break down some of the top reasons pediatric codes or claims are denied and offer practical tips to improve outcomes.
Some Common Pediatric Coding Denials
1. “Bundled Services” or “Included in Global Period”
Example: A claim for a procedure (e.g., vision screening or some testing) is denied because it was billed on the same day as a well-child visit and the payer considers it bundled. Some of these codes are ‘bundled’ based on common coding edits and payer rules. For example, some payers will bundle in vision or hearing screenings with certain well visits.
Consider: While the billing team will check if the provider included modifier -25 and add as appropriate (Modifier 25 indicates provider was performing a significant, separately identifiable E/M service on the same day as a procedure) or in some cases, Modifier 59, payers might still bundle certain services due to payer edits. Ensure documentation supports the need for both services. The billing team evaluates the modifiers associated with certain CPT codes.
2. Incorrect Use of Preventive and Problem-Oriented Visit Codes on the Same Day
Example: A patient comes in for a well visit but is also treated for asthma or an ear infection. If both services are coded but the documentation isn’t clear, one may be denied.
Consider: Select both the preventive code (e.g., 99392) and a problem-focused E/M code (e.g., 99213) with modifier -25 on the E/M. Document both services clearly and separately in the note. Note that many payer terms in the agreement reimburse the E/M code used with a preventive service visit (e.g. 99392) at 50% of the contract rate.
3. Immunization Administration Denials
Example: The vaccine administration code (e.g., 90460) is billed but denied due to missing or mismatched vaccine product codes or lack of counseling documentation.
Consider: Our team links the appropriate administration codes (90460/90461) with the correct vaccine product codes (e.g., 90686, 90715). Ensure the record notes that vaccine risks, benefits, and side effects were reviewed with the caregiver for 90460 eligibility.
4. Invalid Diagnosis Code (ICD-10) for Age or Service
Example: A newborn-specific ICD-10 code is used for a 2-year-old or a screening code is used as a primary diagnosis for a sick visit.
Consider: Double-check age-appropriate ICD-10 codes and ensure they match CPT code intent. Use a problem-specific diagnosis for sick visits and screenings as a secondary diagnosis when applicable. Our team checks the use and order of these codes and makes adjustments as appropriate.
5. Denied Screenings or Labs Due to Missing CLIA Information
Example: In-office lab tests like rapid strep or lead screenings are denied because the practice’s CLIA number was missing or not on file.
Consider: Ensure all lab codes billed in-house are CLIA-waived. Note for certain procedures this data is included with the claim when the procedure is ordered so the provider does not need to insert this information in their note.
Suggestions to Reduce Denials and Improve Revenue Integrity
Provider Documentation Tips
Within the clinical chart, document the reason for the visit, diagnoses, and medical decision-making clearly to support the selected CPT codes.
When adding a sick visit code (99212-99215) to a well visit (99391-99395), explicitly separate the preventive and problem-focused notes and include all the appropriate diagnoses for the visit.
Consider listing vaccine administration counseling by name and content, especially for 90460 compliance.
Workflow Improvements
Implement pre-visit coding checklists for well visits to ensure vaccines, screenings, and preventive codes are properly selected.
Train staff on the use of sick visit code with a well visit, age-specific ICD-10 codes, and payer-specific rules as needed.
Update/enhance clinical templates as needed.
Summary
Many claim denials are preventable and they can significantly improve the revenue cycle for the practice. The key is collaboration: providers, and billing staff must work together to stay up-to-date, document thoroughly, and code precisely. The physicianXpress team continuously enhances the processes and systems to help Pediatric practices minimize denials and optimize total revenue received by the practice.
