Pediatric Billing and Coding Update for 2024 - 3Gen Consulting

1. Pediatric Billing and Coding Update for 2024 Pediatric billing and coding have undergone changes in recent years, and as provider offices head into 2025, it will be important to understand the history of these changes, where pediatric billing has landed after recent updates and its overall impact. Without addressing these changes, pediatric providers risk reduced cash flows, increased stress on their staff, and poor business performance. Staying informed about the latest updates is key to maintaining financial health and operational efficiency in pediatric care. To help support better outcomes for your pediatric billing department, our experts at 3Gen Consulting have put together this overview as a guide. Use it to get caught up with and ready for any challenges in your future. The Previous State of Pediatric Billing Up until 2021 the documentation process in pediatric coding required a considerable amount of effort. The process of documenting an office visit required precision in documenting the exam and patient history as justification for the level of service. But in 2021, CMS introduced the largest billing and coding overhaul of the office-based evaluation and management (E/M) services in over 20 years [1]. It required bringing together representatives from Current Procedural Terminology (CPTⓇ) and the Resource-based Relative Value Scale Update Committee (RUC) as representatives of specialties to develop the optimal approach for moving forward on office-based E/M services, (impacting codes 99201-99215). The ultimate goals were to decrease the burden of documentation and “note bloat”, to address code-level selection and make it more intuitive. They also decided to expand and add to key definitions to decrease the need for audits while retaining the current code distribution. This progressed an approach to pediatric billing and coding that was based on physician activity in treating and managing patient needs, and that moved away from being based on a volume of treatments and tests. Changes to Pediatric Coding in 2021 CMS moved forward with the 2021 changes to medical billing and coding that emerged in a few areas, including [2]: ● Giving clinicians and providers the choice of documenting based on medical decision-making, or the time spent for the visit ● Eliminating the physical and history elements for code selection ● Deleting CPT 99201 ● Shortening prolonged services code (99417) to capture provider time. The code addresses 15-minute increments and is only used with codes 99205 or 99215. The primary code selection basis is time.

2. Additionally, the changes increase the work relative value units (RVU) for visits. For employed physicians, this increased revenue. Updates to Pediatric Coding for 2024 But this year, additional changes in billing and coding have been introduced by CMS, focused around the activation of code G2211. This code is ultimately a benefit for providers, specialists included. Additional documentation is not required to justify billing. Contemporary Pediatrics calls it a “spectacular achievement” and predicts that it will create both discussion and controversy as its use expands. CMS gives these instructions for use: “Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition.” CMS has replaced the time range for assignment of a time element for an E/M code with a threshold. The activation of HCPCS level 2 code G2211 is the most notable change this year. This change was approved back in 2021 and has just completed its implementation moratorium. G2211 is an add-on code for visits under 99202-99205 or 99211-99215. The American Association of Family Physicians (AAFP) has shared insights about the code and billing requirements [3]. G2211 Description Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition, or a complex condition. (add-on code, list separately in addition to office or outpatient E/M (Evaluation and Management) visit, new or established) Updating the Use of G2211 G2211 became reimbursable starting on January 1, 2024 and should be used when a physician is the continuing focal point for all health services that a patient needs. CMS states that the determining factor for when the code should be billed is the relationship between the patient and physician. It should not be used when the relationship with the patient is time-limited, routine or discrete. This includes situations where a patient is seeing a pediatrician for an acute issue if that physician hasn’t assumed responsibility for ongoing medical care and has not planned to do so in the future with continuity and consistency. It also should not be used when the associated office visit E/M is reported with modifier 25 appended. Preparing for Pediatric Billing and Coding in 2025 With the changes that have been implemented, your team will likely need education and training around how they should adjust their work and how their inputs impact your revenue cycle results.

3. Adapting your pediatric medical billing should involve a clear plan to maintain and improve your revenue cycle results. Many pediatric offices, though, struggle to balance labor shortages and the resources needed to keep up with these recent changes. If you need support from an experienced vendor who can free your leadership and team up for higher value tasks, contact 3Gen Consulting today. References [1] American Academy of Pediatrics, "2021 Office-Based E/M Changes," 10 August 2021. Available: https://www.aap.org/en/practice-management/practice-financing/coding-and-valuation/evaluation- and-management/2021-office-based-em-changes2/?srsltid=AfmBOooOzbxA7kfaoTpI0ozCm3udAOR nQ_lrwleMihjA5C-cdL5Z752P. [2] A. J. Schuman, "2024 coding update," 5 June 2024. Available: https://www.contemporarypediatrics.com/view/2024-coding-update. [3] American Academy of Family Physicians, "G2211 Add-on Code: What It Is and When To Use It," Available: https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/evaluation-manage ment/G2211-what-it-is-and-how-to-use-it.html. Original Source - https://www.3genconsulting.com/pediatric-billing-and-coding-update-for-2024/