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Pediatric CPT codes are used to identify procedures and services that are primarily provided to children in medical operations. These codes are essential for pediatric billing and reimbursement; therefore, medical professionals must properly label each service to ensure proper payment.

Insurance companies can better manage claims with the help of pediatric CPT codes. These codes ensure correct billing to insurance providers, minimizing the chance of insurance claims being denied. With better insurance claim handling, the time it takes for patients to get paid by their insurance providers can be shortened.

Numerous pediatricians frequently operate at a loss while providing particular types of care without making a profit. For instance, the clinic can have extra costs due to the vaccinations they offer. However, they try because they know how vital vaccinations are to children’s health and the country.

Without any more delay, let’s examine some of the CPT codes used most commonly in pediatric practice.

Evaluation & Management (E/M) codes

E/M codes describe patient visits to primary care physicians, specialists, and hospitals’ emergency rooms. When assigning these numbers to medical professionals, the level of care provided to patients is considered. These are the most often used E/M codes for pediatric practice:

  • 99213: Level 3 appointment-based care for existing patients

A moderate level of medical decision-making is required for this code, which describes an established patient’s office visit. Follow-up appointments that are not urgent should use this code.

  • 99214: Level 4 existing patient visit at the office

This code describes established patient office visits requiring significant medical judgment. This is the go-to billing code for doctor’s appointments that address several severe health concerns.

  • 99203: Level 3 new patient’s first consultation

This code describes a new patient office visit requiring some medical judgment.

  • 99204: Level 4 office visit initial visit

This code describes a new patient office visit that needs more complex medical decision-making.

Preventive medicine services

Services in preventive medicine aim to improve and safeguard people’s health. Most pediatricians rely on the following preventive medicine services:

  • 99381: New patient check-up younger than a year

A new patient under the age of one who is being seen for preventative care is identified by this code.

  • 99382: New-patients primary care check-ups every 1–4 years

This is the billing code for a well-child check-up for a kid between the ages of one and four.

  • 99383: Primary care check-ups for children aged 5-11 years

A new patient between the ages of 5 and 11 who are being seen for preventative care is identified by this code.

  • 99391: Establishes patients’ regular check-ups within the past year

This code describes preventive care for a specified patient younger than one year.

  • 99392: Wellness check-ups for existing patients, once every 1–4 years

This code denotes a wellness check-up for an established patient between the ages of one and four.

  • 99393: Established patient, the 5-11-year interval for preventative care

A well-established patient between the ages of 5 and 11 is described by this code, which indicates a preventive visit.

Administrative codes for vaccinations

Codes for the administration of vaccinations are used to characterize the process. Pediatricians typically use the following vaccination administration codes:

  • 90460: Counseling and vaccinations for kids up to age 18

This code describes the vaccination of a patient under 18 who also received counseling.

  • 90461: Administration of vaccines without advice till the age of 18

This code describes when a patient under 18 is vaccinated without prior counseling.

Diagnosis codes and medical laboratory

Codes in the laboratory and medical fields describe various diagnostic procedures and laboratory testing. The most frequently used laboratory and diagnostic codes in pediatrics are as follows:

  • 81002: Non-microscopic automated urinalysis

This code indicates a urinalysis that does not require a microscope. This type of urinalysis is performed using automated equipment that can analyze a patient’s urine’s chemical and physical properties, such as pH, protein levels, glucose levels, and red and white blood cells.

  • 87880: Strep test results

This code is assigned to a quick strep test to identify if the Group A Streptococcus bacterium is present in a patient’s throat. The test involves swabbing the patient’s throat and analyzing the sample for the presence of the bacteria.

  • 85025: Blood count, complete (CBC)

Hemoglobin levels, platelet counts, and the number of red and white blood cells are all described by this code.

Other common CPT codes

In addition to the codes mentioned above, pediatricians also use a variety of others. For example:

  • 99211: Level 1 established patient visits to the doctor’s office

This code is used to identify an office visit for an established patient that involves minimal medical decision-making.

  • 99401: Individualized risk factor reduction and preventative counseling, 15 minutes

Individual preventive counseling sessions of 15 minutes duration are described using this code.

  • 99402: Risk factor reduction and preventative counseling, 30 minutes for each person

This code describes a preventative counseling session that lasts for 30 minutes and is aimed at reducing the risk factors for a particular condition or disease.

  • 99395: Established patients’ preventative medical check-ups aged 18–39

This code describes a preventative medical check-up for a verified patient between 18 and 39.

  • 99396: Patients preventive healthcare aged 40 to 64

This code describes a preventative healthcare visit for an established patient between 40 and 64.

Conclusion

Knowing the most common CPT codes used in pediatrics is crucial for proper medical billing and coding. For healthcare professionals like doctors and nurses who aim to provide the best care for their young patients, accurate documentation and coding can help them achieve so.

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