Under Coding by a Pediatric Provider or Pediatric Practice

 Under coding or under billing by pediatricians refers to a situation where the services provided to patients are not accurately coded or billed at the appropriate level, resulting in lower reimbursement than deserved. This can have several impacts on the pediatric practice:

•  Financial implications: Under coding or under billing can lead to decreased revenue for the pediatric practice. If services are consistently undercoded or underbilled, the practice may not receive adequate reimbursement for the care provided, which can affect financial sustainability and the ability to invest in resources, equipment, and staff.
•  Inaccurate financial reporting: Undercoding can distort financial reports and analytics within the pediatric practice. This can impact strategic decision-making, making it difficult to assess the financial health of the practice, identify areas for improvement, or accurately project future revenue and expenses.
•  Quality of care implications: Undercoding may affect the perceived value and quality of care provided by the pediatric practice. Lower reimbursement can potentially impact the resources available for delivering high-quality care, such as investment in staff training, advanced technology, or additional support services.
• Inappropriate data for analytics of Payers: Each practice that under codes provides inaccurate data that can lower the benchmarks such as the average % utilization of each E&M code (99212-99215).   It is essential for pediatric practices to adhere to coding guidelines and accurately reflect the services provided to avoid sending the payer data that does not reflect the true level of services provided..
•  Provider dissatisfaction: Undercoding can also impact provider satisfaction within the pediatric practice. If providers consistently feel that their services are undervalued or not adequately reimbursed, it may lead to frustration, demotivation, or even potential attrition, affecting the overall morale and stability of the practice.

 To mitigate the impact of undercoding or under billing, pediatric practices should prioritize accurate coding and billing practices. Regular education and training of providers on coding guidelines and documentation requirements can help ensure proper reimbursement for services rendered. Utilizing technology solutions and conducting regular audits or reviews of coding practices can also assist in identifying and addressing any undercoding issues proactively.

Examples of UnderCoding in Pediatric Practices

Under coding by pediatricians refers to the practice of assigning lower-level billing codes for services than what is supported by the documentation and medical necessity. Here are a few hypothetical examples that illustrate potential instances of under coding by pediatricians:

• Evaluation and Management (E/M) visits: A pediatrician consistently selects a lower-level E/M code (e.g., level 2 or 3) for visits that involve a more comprehensive history, examination, and medical decision-making. This results in lower reimbursement than warranted based on the complexity and time spent on the visit.
• Chronic disease management: A pediatrician provides ongoing care and management for a child with a chronic condition, such as asthma or diabetes. However, they consistently select lower-level E/M codes for these visits, failing to capture the complexity and intensity of the services provided.
•  Counseling and coordination of care: A pediatrician spends significant time counseling patients and their families, providing education, or coordinating care with other healthcare professionals. However, they consistently undercode the time spent, resulting in lower reimbursement for these services.
•  Preventive care services: A pediatrician provides comprehensive preventive care services, including age-appropriate screenings and counseling. However, they consistently select preventive care codes that do not accurately reflect the extent of the services provided, leading to undercoding.  An example of this would be if the practice conducts a well visit and the patient or parent completes a SWYC scoring tool and then the provider only selects the well visit code but does not select the CPT code (96110) associated with the scoring tool completed.

 It is important to note that these examples are purely hypothetical and are meant to illustrate potential scenarios of under coding in pediatrics. Actual cases would require a thorough review of medical records, documentation, and coding practices to determine if under coding has occurred. It is crucial for pediatricians to accurately document and code services based on the complexity and medical necessity to ensure appropriate reimbursement for the care provided.