Common Pediatric Billing & Coding Mistakes to Avoid

Pediatric care is a field that is devoted to the health and well-being of the youngest patients. In every treatment, there is a complicated administrative environment, ie, pediatric billing and coding. 

In most practices, the critical role is a minefield of mistakes, causing a lot of financial consequences. Healthcare denial rates range from 5-10%, and in certain specialties, the number may be even higher; compliance fines are expensive. 

In this blog, you’ll find common errors in medical billing for pediatrics are not only regarding financial well-being; it is also about quality patient services that are sustainable.

7 Common Errors in Pediatric Billing and Coding

1. Misuse of Modifiers

The modifiers offer supplementary facts regarding a service/ procedure. Their incorrect application or omission, particularly when using widely used CPT codes in pediatric care, such as vaccination codes or sick visits, inclusive of well-child check-ups, will result in instant rejections. 

Using modifier 25 in the place of a significant, separately identifiable evaluation and management service on the same day as a procedure is a common culprit.

2. Outdated CPT and ICD-10 Codes

The healthcare coding environment is dynamic. Their inability to keep up with yearly changes in CPT and ICD-10 codes can be attributed to a variety of denials. New codes are added, old ones are updated, and some are even removed completely.

3. Poor Documentation

This is possibly the cause of most documentation errors in pediatrics. Payers will reject the claim in case the medical record does not explicitly substantiate the services being billed. 

Missing information regarding the complexity of the E/M visit, incomplete histories, or justification of medical necessity. It should always be in the form of a mantra (If it was not written, it was not done).

4. Bundling Errors

A lot of the procedures are bundled; that is, some services are deemed to be part and parcel of a bigger procedure, and they should not be charged independently. The unbundling of such services, whether deliberate or not, may initiate audits and denials.

5. Lapse of Checking Insurance Eligibility

It may appear to be a simple step, but not checking the insurance or not rechecking the eligibility before further visits, services might be offered to the patient with lapsed or changed cover, and the practice will be left with unbilled patients.

6. Under-coding/ Over-coding

Under-coding refers to charging a lesser service than the one done, and hence, revenue loss. On the other hand, over-coding refers to the process of charging a higher or more complicated service than it was rendered or documented, and this can attract attention to fraud and abuse.

7. Lack of Adherence to Payer-Specific Rules 

Every insurance payer possesses a specific set of rules and policies, and guidelines for claim submission. What may be accepted by one payer may not be accepted by another. The inability to interpret and comply with these particular requirements is a frequent cause of being denied claims based on pediatrics.

Related: What Benefits Does a Customizable Pediatric Module in EHR Offer for Pediatric Care?

Practical Fixes and Audit Tips for Enhanced Billing Accuracy

1. Invest in Continued Education – It is most important to invest in regular training of your coding and billing staff and even clinicians on the best documentation practices. Keep up with the changes in the codes annually, as well as payers. Think of certified professional coders on your team.

2. Use Technology – Have strong EHR and practice management systems that have in-built coding edits and claim scrubbing capacities. These tools are able to identify numerous errors prior to claim submission.

3. Enforce a Strong Internal Auditing Structure – A periodic internal audit of the pediatric practices – internal coding audit- is essential. Select a random percentage of charts each month to check against the documentation of the billed services. This assists in determining the trends of inaccuracy and improvement points.

4. Pay attention to the Quality of Documentation – Train providers on the need for complete and detailed documentation. Templates used by the clinicians can facilitate the process of capturing all the required information every time. Give effective samples of what makes good documentation of different pediatric CPT codes.

5. Proactive Payer Communication – Form a relationship with the regularly used payers. Know about their certain policies and their webinars or workshops.

Your Pediatric Billing Compliance Checklist

HIPAA Compliance

• Would all the patient records and billing information be secure based on the HIPAA requirements?
• Are employees under periodic HIPAA training?
• Do Business Associate Agreements exist with all vendors that deal with Protected Health Information?

Payer-Specific Rules

• Do you have the current policy manuals of your top payers?
• Does your team understand the denial patterns of all payers?
• Do you habitually check payer newsletters and updates?

Medical Necessity

• Do all services have a medical necessity that is well recorded in the chart of a patient?
• Do the clinical findings support and provide specific diagnoses?

Coding Accuracy

• Do you regularly review CPT codes and ICD-10 codes to make sure they are accurate and up-to-date?
• Do we use modifiers appropriately and correctly?
• Does it have a procedure for reviewing and appealing denied claims promptly?

Documentation Integrity

• Does it have all the documentation that is abbreviated, exhaustive, and timely?
• Is the documentation justification for the level of service billed?
• Are all the ordered tests and referrals documented?

Regular Audits

• Do internal coding and billing audits occur regularly?
• Are external audits taken periodically to make an objective review?
• Are corrective measures taken on the findings of the audit?

Vozo Pediatric Billing & Coding Solution

With Vozo’s Pediatric Billing & Coding Solution, your practice gains accuracy, compliance, and complete control over revenue, all within one intelligent cloud-based platform.

Our solution is designed to simplify pediatric billing workflows, prevent costly coding mistakes, and ensure every claim meets payer and compliance standards.

With Vozo, you get:

• Built-in pediatric CPT & ICD-10 code libraries with auto-updates
• Real-time claim scrubbing and denial prevention tools
• Automated eligibility checks and payer-specific rule validation
• Centralized dashboards to track reimbursements and coding performance
• HIPAA-compliant security and pediatric-focused audit trails
• Smart reporting to identify revenue gaps and optimize claims

Vozo’s Pediatric Billing & Coding Solution empowers pediatric practices to minimize errors, reduce denials, and accelerate payments, creating a workflow that’s smarter, faster, and more compliant.

Streamline your pediatric billing today with Vozo. Book your free demo now.