5 Services Pediatricians Forget to Bill For

Betsy Nicoletti, MS


November 01, 2018

In This Article

Using Transitional Care Management Codes Properly

Pediatric patients aren't admitted to the hospital at the same frequency as adult patients, but when patients with acute or chronic conditions are hospitalized, they may need the services defined by transitional care management (TCM).

These CPT codes provide higher payment than a follow-up visit . The service includes direct contact with the patient/parent/caregiver in 2 business days, a face-to-face visit with the patient within 7 or 14 days, medication reconciliation no later than the day of the visit, reviewing the discharge summary, and non–face-to-face services performed by the pediatrician or other practitioner or clinical staff.

TCM (Table 3) can be used for patients being discharged from an inpatient or observation admission, skilled nursing, and partial hospitalization. For example, a 10-year-old is admitted to observation for an exacerbation of asthma. After discharge, the clinical staff at the pediatric practice calls the parent within 2 business days, and checks on how the patient is doing. A follow-up visit is scheduled with the pediatrician for day 8. At that time, the discharge summary is reviewed and medications reconciled. After the visit, the clinical staff calls the parent another time, to reinforce the correct use of inhalers and discusses removing allergens from the home, and the importance of avoiding secondhand smoke. Bill for the TCM service on the day of the office visit.

Table 3. CPT Codes for Transitional Care Management

Code Description wRVUs
99495 Transitional care management, 14-day visit, moderate MDM 2.11
99496 Transitional care management, 7-day visit, high MDM 3.05
99214 Office/outpatient visit, established, level 4 1.5
99215 Office/outpatient visit, established, level 5 2.11
CPT = Current Procedural Terminology; MDM = medical decision-making

If Ancillary Services and Lab Tests Are Ordered, Bill for Them

Lab tests are less likely to be forgotten with electronic order entry, but there are still verbal orders and the chance that a lab test is ordered, documented, and not billed for.

Injections can be a source of lost revenue when either the administration or the medication/vaccine is not billed. If a medication code or a vaccine code is billed, there should also be an administration code.

Sometimes, the patient provides the medication or allergy serum or the state provides the vaccine. In that case, bill only for the administration. This complicates the billing, because the clinical staff needs to be vigilant in knowing whether the practice paid for the medication/serum or not, and bill accordingly.

Coding correctly and collections are important. But, before those two steps, capture all the charges for the services that were done.


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