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Pediatric Coding Alert

2020 Reimbursement:

Take Away These 3 Pieces of Post-COVID Advice for Your Pediatric Practice

 Telemedicine increases help offset reduced visit and vaccination revenues.

Pediatric practices, like everyone else in this country, have been dramatically affected by the COVID-19 public health emergency (PHE).

But by how much? Chip Hart, director of PCC’s Pediatric Solutions Consulting Group in Vermont and author of the blog “Confessions of a Pediatric Practice Consultant,” has provided the following data to show how pediatric practices are weathering the storm.

Sick Visits Down, Well Visits Rebound

Hart’s data shows that, in mid-March when many states went into lockdown, pediatric practices showed dramatic drops in sick and well visits. (Source:

Why? “We suspect this is due to a couple of factors. First, stay at home orders intended to reduce the spread of COVID-19 through contact with infected people have the same effect on other illnesses. Second, March is a typical time period for flu season to subside, leading to a natural drop in sick visit rates,” says Hart.

Hart’s data echoes the experience of other providers across the country. “All our clients have seen a decrease in volumes. If they do see patients in office, they are seeing them for emergent cases only,” observes Jessica Miller, CPC, CPC-P, CGIC, manager of professional coding for Ciox Health in Alpharetta, Georgia 

By mid-April, however, while sick visits were still significantly low, Hart’s data shows that well visits began to pick up and continued to increase in volume into May. Given this uptick, Hart advises pediatric practices to review and provide the full-range of age-appropriate preventive medicine services as recommended by Bright Futures (see, for example, and coded per the American Academy of Pediatrics coding resource found at: >

Takeaway 1: “Preventive care is vital for the health of the country and the viability of pediatricians,” Hart believes.

Vaccination Rates Plummet …

By the end of April, data also indicated some significant decreases in vaccination rates: MMR was “off by 53%, HepA volume off by 51%, HPV by 73 percent, and flu down a whopping 83 percent,” Hart’s data showed (Source:

Some of this decline is seasonal. Flu infection rates, for example, were already trending down. And many of the immunizations involved boosters that pediatricians, parents, and patients could easily defer to dates when it would be safer for in-person office visits, Hart asserts.

Even so, the data provide yet another reason to meticulously document 90460/+90461 (Immunization administration through 18 years of age via any route of administration, with counseling …), 90471/+90472 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) …), and 90473/+90474 (Immunization administration by intranasal or oral route …) along with the cost of the vaccines administered to ensure your practice is being reimbursed to the fullest possible extent for immunization services.

Takeaway 2: “We don’t yet know how long COVID will impact immunization opportunities,” Hart cautions.

… While Telemedicine Skyrockets

“Almost all of my clients have seen a rise in telehealth visits. They are up significantly,” Miller observes. This is also borne out by Hart’s data, which shows a huge, yet unsurprising, increase in telemedicine during the emergency, rising from around 10 percent in the middle of March to a steady 35-40 percent throughout April and into May.

This presents a significant opportunity for pediatric practices, at least for the moment. That’s because the Centers for Medicare & Medicaid Services’ (CMS’) revision of its resource-based relative value scale (RBRVS) on May 1, 2020 included significant increases in the valuation of 99441-99443 (Telephone evaluation and management service by a physician or other qualified health care professional).

The new RBRVS remapped the codes so that 99441 pays the same as 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …), while 99442 pays the same as 99213, and 99443 the same as 99214.

This means the telephone codes now pay “$46.19, $76.15, and $110.43. Those are improvements of 320 percent, 271 percent, and 268 percent, respectively.” In other words, “a 21-30 minute phone call pays the same as a 99214,” Hart points out.

However, “even with the additional payments allowed from Medicare, payers they are still going to see a reduction in revenues since this will not offset elective procedures,” Miller cautions.

Takeaway 3: “I believe telehealth visits will largely replace office visits, especially for follow-ups and minor symptoms such as sore throat or ear pain. My clients

mostly believe patients will continue to prefer telehealth versus face-to-face visits in the near future — and likely beyond that — especially for children, who are still considered high risk,” Miller believes.

So, too, does Hart. “Telemedicine is here to stay; it’s going to be a matter of how it’s used, and who is going to pay for it. Some payers have been excellent partners, while others have shown some real avarice,” Hart concludes.