The CPT codes used to represent medical operations and services delivered mainly to children are called pediatric CPT codes. These codes are a subset of the CPT codes used to describe adult medical conditions and procedures. Medical providers must appropriately label each service to ensure proper payment using these codes, which are critical for pediatric billing and reimbursement.

CPT codes for pediatrics help insurance companies handle claims better. These codes guarantee accurate billing to insurance companies, lowering the possibility of insurance claim rejections. The time it takes for patients to receive reimbursement from their insurance companies can be reduced with better insurance claim handling.

Numerous pediatricians provide specific categories of care without making a profit and are frequently at a loss. For instance, the clinic may incur additional expenses due to the vaccinations they provide.  However, they make an effort because they know vaccinations are crucial to children’s and the country’s health.

Let’s look into some of the most frequently used CPT codes in pediatrics without further ado.

E/M Codes for Evaluation and Management

Visits to the doctor’s office, a specialist’s office, or the emergency room can all be described with E/M codes. These codes are determined by the healthcare professional’s level of service to their patients. The most prevalent pediatric E/M codes are:

99213 – Appointment-based Level 3 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 Visit by an Existing Patient to an 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 First Consultation for a New Patient

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

99204 – Level 4 Initial patient office visit

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

Services for Preventative Medicine

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

99381 – Check-up for new patients 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 – Primary care check-ups for new patients 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 old

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

99391 – Regular check-ups for established patients within the past year

This code describes preventive care for an established patient younger than one year.

99392 – Existing patient wellness check-ups, 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 immunizations

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

90460 – Counseling and immunizations 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.

Medical Laboratory and Diagnosis Codes

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 – Automated urinalysis that does not require a microscope

This code indicates a urinalysis that does not require a microscope.

87880 – The results of a Strep A test

This code is assigned to a quick strep test to identify if Group A Streptococcus bacteria are present in a patient’s throat.

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 Frequent 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.

Individual sessions of preventative counseling lasting 30 minutes each are described using this code.

99395 – Preventative medical check-ups for established patients aged 18–39

Use this code to denote a wellness check-up for an established patient aged 18–39.

99396 – Preventative health care for patients aged 40 to 64

A preventive visit for a known patient between the ages of 40 and 64 is denoted by this code.

Conclusion

For accurate and effective medical billing and coding, it’s essential to understand typical CPT codes in pediatrics. As doctors and nurses try to give their young patients the best care possible, proper documentation and coding can help ensure that the right resources are used for the best results.