Pediatric Coding Alert

Plus: Office-based well child visits also get a raise.

You may not treat Medicare patients, but most pediatricians know that private carriers frequently base payment rates on the Medicare Physician Fee Schedule--and this year, you'll be seeing significant pay raises to many of the most commonly-billed pediatric codes.

Background: The Centers for Medicare & Medicaid Services (CMS) updates its fee schedule on a quarterly basis. The fee schedule assigns different relative value units (RVUs) to every available CPT code. Most insurers subsequently use those values to set rates for physician services, even for non-Medicare patients--which is why these values are important to pediatricians.

Most code values do not change dramatically from one year to the next. For instance, code 99213 (Office or other outpatient visit...) was assigned 0.97 RVUs in both 2011 and 2012. When multiplied by Medicare's conversion factor of $34.0376, that code pays about $33.00.

Other codes, however, saw dramatic pay increases in 2012--a welcome change for pediatricians who felt those codes were undervalued. For example, you'll see a startling 61 percent increase in the payment for code 99460 (Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant). Although you had a relative value base of $40 for this code last year (when it had 1.17 RVUs), you'll see $65 for the same service this year (thanks to an RVU increase to 1.92).

You'll Benefit From Several New Payment Avenues

Although not as dramatic a raise as 99460, other codes also saw increases in RVUs for 2012. You'll find Medicare-equivalent income boosts to the following codes that impact pediatricians:

Remember: If your payer follows Medicare's fee schedule, you should already be seeing these payment increases for your 2012 services. Take a look at your recent superbills to determine whether you need to follow up on any of your claims to ensure that they are paid accurately. Check out our clip and save below for more information on how to analyze your accounts receivable to optimize your payments.

To access more information about the Medicare Physician Fee Schedule, visit www.cms.gov/PhysicianFeeSched/.