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August is one of the busiest months in pediatric offices. Families are preparing for the school year, which means a sharp increase in well visits, sports physicals, vaccine updates, and late-summer sick visits. While this brings a surge in patient volume, it also comes with common billing pitfalls that can impact a practice’s revenue cycle. Below are several issues pediatric practices should be mindful of this August, along with recommendations to minimize denials and delays.
1. Well Visit vs. Sports Physical Coding Issues
Many families request a “sports physical” when scheduling a back-to-school checkup. The challenge arises when the provider documents both a well child visit (CPT 99392–99394) and uses the ICD-10 diagnosis code Z02.5 (Encounter for examination for participation in sport).
Why this matters:
Some payers deny the well visit if Z02.5 is the only ICD-10 diagnosis used, treating it as a non-covered service.
If both the comprehensive preventive exam and the sports clearance are performed, Z02.5 should be listed as a secondary diagnosis—with the age-appropriate preventive ICD-10 code (e.g., Z00.129 – routine child health exam without abnormal findings) as the primary.
Tip for practices: Train providers and billing teams to ensure proper sequencing of ICD-10 codes. Document the preventive visit thoroughly and add Z02.5 as a supporting diagnosis, not the primary one. This helps support coverage under the preventive service benefit.
2. Insurance Verification Gaps at the Front Desk
The August rush puts extra strain on front desk teams. If staff don’t carefully verify eligibility, practices risk denials for preventive visits, vaccines, or same-day sick visits.
Common issues include:
Patients who recently changed insurance plans over the summer (common with job changes or Medicaid redeterminations).
Out-of-network visits mistakenly scheduled as covered.
Vaccine administration codes denied because the plan doesn’t cover immunizations outside a state vaccine program.
Tip for practices:
Use electronic eligibility tools daily.
Flag patients with secondary insurance to confirm which plan is primary.
A five-minute eligibility check can prevent weeks of claim resubmissions and lost revenue.
3. Late-Summer Sick Visits: Allergies, Asthma, and Bug Bites
Alongside well visits, August brings an uptick in sick visits related to seasonal allergies, asthma flare-ups, and bug bites.
Billing challenges to watch for:
Asthma visits: Ensure that both the acute episode (e.g., J45.901 – unspecified asthma with acute exacerbation) and the underlying asthma diagnosis are coded properly.
Allergic reactions: Clarify whether the visit is for environmental allergies (e.g., J30.1 – allergic rhinitis due to pollen) vs. an acute reaction that might require a different ICD-10 code.
Bug bites: Document whether the bite is infected (L03.9 – cellulitis, unspecified site) vs. non-infected (T07 – insect bite, unspecified).
Accurate documentation supports proper E/M coding (99213–99214) and reduces the risk of denials for “non-specific” codes.
Key Takeaways for August 2025
Well Visits + Sports Physicals: Bill preventive codes with Z02.5 as secondary, not primary.
Insurance Verification: Reinforce front desk training and tools to reduce vaccine and visit denials.
Sick Visits: Encourage providers to be precise in documenting asthma, allergy, and insect bite visits.
With the right preparation, practices can turn August’s high-volume month into a revenue-positive period, instead of chasing down preventable denials in September.
Physician Xpress, Inc. specializes in pediatric EHR and RCM services designed to help practices avoid these common pitfalls. Our team monitors payer trends, denials, and coding updates so your practice can focus on patient care.
