Tips for Pediatric Billing and Coding in 2023

As 2023 kicks off, now is a great time for pediatric revenue cycle leaders to take a step back and review ways they can set themselves up for success, reevaluating some of their priorities and best practices. For many leaders, this can involve everything from renewed focus on efficiency to reviewing your relationship with pediatric medical billing companies.

Review Your Current Coding Landscape
Before you get into any area where you might want to make changes, review where you stand now. Look at your claims, denials, and appeals processes. Take time to look at contract performance and your contracting processes. Sit down to review compliance and what standardized code sets you’re currently using, including CPT and ICD-10-CM. If you have relationships with pediatric medical billing companies, now is a good time to review them.

Look at how your current revenue cycle is structured, your software and staffing profile, and the systems and processes you’re using to measure results. Also, don’t forget to take some time with your care management and how you’re creating care plans, including who’s responsible and how you’re documenting and communicating your plans. This is also a good time to look at your approach to telehealth – extending to both telemedicine and remote work.

Focus on Efficiency
Efficiency in your pediatric medical billing will be critical in 2023. As staff shortages continue and pediatric practices are expected to do more with less, efficiency practices will help avoid holes and bottlenecks that can slow your cash flows and increase costs.

Make sure you’re set up properly to submit clean claims as much as possible. “Garbage in, garbage out” can be more of a drag on your revenue cycle than poor workflows. Look for root causes of issues that lead to denials such as prior authorization and precertification issues, missing or invalid claim dates, and inaccurate eligibility or registration information. If you find patterns in the causes, take the time to address these so the issues don’t continue to trickle down and drain your revenue cycle efficiency. Your options in addressing them will include:

  • Claim scrubbing tools that identify potential issues before claims go to adjudication
  • Making sure you’re staying on top of payer updates
  • Ensuring your medical billing and coding staff are trained on the most up-to-date code sets and claim submission requirements
  • Working with pediatric medical billing companies who prioritize efficiency and results

Keep in mind that you should be aiming for a clean claims rate of above 90%, so if you aren’t close, know that this should be an area of intense focus for 2023, including evaluating pediatric medical billing and coding services [1].

Optimize Your Billing
Focusing on this area specifically can translate into huge gains in your revenue cycle outcomes for 2023. Consider that, according to Contemporary Pediatrics, physicians tend to undercode for their office visits – 99213 visits are generally paid at $30 to $50 lower than 99214, which requires moderate medical decision making. Make sure you’re considering this code when you see patients who align with at least one of the following [2].

  • Two or more stable chronic illnesses such as asthma or enuresis
  • A condition that requires management with prescription drugs such as UTI
  • At least one chronic illness that has mild exacerbation, progression, or adverse effects of treatment, such as attention-deficit/hyperactivity disorder not responding to medication
  • An undiagnosed new problem with uncertain prognosis, such as blood in the patient’s stool
  • Acute complicated injury, such as head injury with brief loss of consciousness
  • Acute illness with system symptoms, such as pneumonitis or colitis

If you find issues like this to be prevalent, take some time to review your coding software and talk with your coding professionals to ensure they’re properly trained and understand the downstream implications of their work. 2023 might be a good year to invest more in training or pediatric medical billing and coding services.

Reduce Your Overhead
2023 is shaping up to be a good year to get overhead in pediatric practices under control. For example, if you’re shopping for practice management, revenue cycle, or telemedicine software, make sure to take the time to compare pricing (both up-front and long-term) to make smart decisions.

Take time to do the financial math on patient portals. While physical mail and calls are more effective in some areas, it’s very possible that many of your efforts could be automated, saving money on postage and staff hours, freeing them up for higher-value tasks. Modern portal solutions have advanced functionality that even help support your revenue cycle efforts with bill viewing and payment that can encourage faster resolution of balances.

Also look at your high-priced items like copiers and photoscreeners, keeping an eye out for where you can reduce costs through leasing agreements that also allow you to keep technology up-to-date, avoiding the creeping burden of tech obsolescence. Take advantage of member discounted rates via group purchasing services such as the ones offered via Physicians’ Alliance of America and Physicians’ Buying Group when buying items like table paper, needles, and syringes.

Some practices have also seen success with no-show policies to discourage and reduce missed appointments. This can include giving patients one missed appointment free, but charging after that and even dismissing frequent offenders.

Most importantly, take 2023 to prioritize optimizing your staffing decisions. Your nurses shouldn’t be doing the work of a medical assistant, especially as burnout rates have increased. By making sure that your staff are performing the tasks they’re trained to do and not taking on duties that should be performed by another professional, you can help reduce stress and improve retention rates [2].

Protect Your Future
Pediatric revenue cycle leaders are facing many uncertainties, but there are ways that you can make your future look a little more predictable. When cash flows are higher, make sure you’re maintaining a cash reserve. Similarly, maintain a line of credit that you can access in leaner times. If you aren’t already, start investigating pediatric medical billing companies who can act as a support in an uncertain future of the pediatric revenue cycle. You can start that process here.

[1] “4 proven strategies for optimizing revenue cycle performance,” Healthcare Financial Management Association, 8 July 2022. Available:
[2] A. J. Schuman, “The business of being a pediatrician,” Contemporary PEDS Journal, vol. 39, no. 4, May 2022.

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