Presenters: Heather Collette, MD, Jessica Ford-Davis, DO, Andrea Hadley, MD, and Jack Percelay, MD
This interactive, case-based PHM 2023 presentation discussed the new pediatric inpatient billing guidelines that went into effect in January 2023. It is important to bill accurately, not only to avoid fraud but also to represent the work done caring for high-risk pediatric patients.
Many of the documentation requirements, including past medical history and review of systems, are no longer required. The level of billing is solely based on either time or medical decision making. This allows for more clear and concise documentation. The time thresholds for each level of billing are higher, but the activities that account for this time have expanded. There are new prolonged service codes to better account for the total time taken to care for the patient.
Billing level can be based on medical decision making, including problems addressed, data reviewed and/or analyzed, and risk of management. The risk of managing pediatric patients should not be underestimated and does not correlate to the risk of managing adult patients. For example, the risk of gastroenteritis and dehydration in an infant is much higher than managing the same diagnoses in an adult patient.
There are no longer observation codes; this allows physicians to bill for pediatric admissions without making a distinction between inpatient and observation status. Additionally, there are both critical care and neonatal intensive care billing codes that can be used when caring for critically ill and <28-day-old neonatal patients, respectively, as inpatient pediatric patients.
- Pediatric patients aren’t just small adult patients and the risks of caring for pediatric patients are not the same as the risks in the adult patient population.
- Billing can be based on medical decision making or time. The time criteria for inpatient billing changed with the newly updated billing guidelines, but so did the activities that account for that time. Choose wisely between using medical decision making or time to ensure you are capturing all of the work performed in 24 hours.
- Despite the new billing and coding guidelines being more than six months old, there are still no clear standards around these guidelines. With the new documentation changes, there should be a shift to writing more concise and relevant notes. Additionally, there is an opportunity to have local influence and implement cultural changes.
Dr. Camp Sanders is a pediatric hospitalist at Arkansas Children’s Hospital and is faculty at the University of Arkansas for Medical Sciences in Little Rock, Ark. She also serves as the medical director for the statewide Arkansas Children’s Operations Center.