- Preventive or Well Exam code classified based on patients age. Need to verify the Child’s DOB to use appropriate 5th digit of the Preventive E/M Code.
- Hearing (CPT 92551) & Eye (CPT-99173) screening in addition to the Preventive exam CPTs but most of the insurances will not cover it and deny as inclusive.
- Bill 96100 for psychological testing with appropriate modifiers.
2. Vaccination:
Another major service in Pediatric Medical Billing is Vaccinations which includes the following billing and coding nuances:
- We need to use the modifier “SL” if the vaccine is state supplied under VFC program (Vaccine for Children). If provider is using private in such a case claims need to submit without “SL” Modifier. Provider will lose money if we use modifier and will not be paid by the insurance.
- Main concern here is the need to bill Administration with correct units to get payment for the provider.
- Medicaid guidelines should be checked appropriately when processing Medicaid MCOs to bill vaccination. Based on our experience handling pediatric billing we found, the payment for vaccination varies by administration CPT and Vaccine CPT by State. Such state specific variations are to be keenly noted to process claims accordingly to meet the Medical Billing state specifications.
- 90460 – Immunization administration through 18 years of age via any route of administration with counseling by physician or other qualified health care professional, first or only component of each vaccine or toxoid administered90461 – each additional vaccine or toxoid component administered
3. Coverage Related:
When we speak about pediatric billing which majorly covers the new borns, infants and children below 17 years of age, we encounter coverage related issues denial. Few insurance assign ID separately even for the child and need to bill under that ID number but with some insurance it takes time to create a new ID for the new born and claim needs to be billed under Mother’s Ins ID.
However, when we bill under Parent’s ID need to double check the “Relationship to the subscriber” to avoid denials.
If it goes as “Self” by mistake, we receive denials as follows which is not related coding related issues, marking the correct gender, age and relationship with the subscriber are common denial reason.
4. Patient Statement:
In Pediatrics Medical Billing, we need to have a check list to review Guarantor’s information before sending the statement to the patients (Child).
With the above Medical billing and coding nuances; handling Pediatric billing inhouse can be highly challenging! Find one stop solution with MGSI as your medical billing service partner for all you medical billing and RCM needs
