Summary of presentation from Dr. Richard Lander at a previous PMI Conference
CPT (Current Procedural Terminology) coding is fundamental to the financial health and legal security of every pediatric practice. In a recent presentation, expert educator Dr. Richard Lander offered a practical, experience-driven overview of CPT basics, key changes in coding requirements, frequent insurance pitfalls, and ways to optimize revenue without compromising ethical standards. This article synthesizes the main points from his talk, summarizing crucial concepts for pediatricians and practice managers and ending with actionable takeaways.
The landscape of CPT coding has evolved immensely over the last few decades, becoming both more complex and more critical to daily pediatric practice. Dr. Lander highlighted that CPT codes communicate the exact nature of each service provided to insurers, determining not only if, but also how much, practitioners get paid. Crucially, contracted rates for CPT codes can vary greatly by region and insurer, and these rates change annually. Pediatricians must also consider their RVUs (Relative Value Units), which quantify the value of services rendered and are often used for bonuses or salary determination in employed settings.
Correct pairing of CPT codes with ICD-10 diagnosis codes is essential; ICD-10 codes denote the medical necessity behind services, and their correct use—updated annually—is mandatory for payment. Additionally, codes for medications, supplies, and procedures (such as immunizations or asthma treatments) must be used precisely to capture legitimate revenue. Dr. Lander emphasized that supplies and medication administrations are frequently underbilled and that underpayment is pervasive; diligent practices must regularly check EOBs (Explanation of Benefits) and be prepared to challenge breaches of contract or errors—sometimes using organized tools like a "hassle factor" form sent to state or national advocacy bodies.
Inaccurate or careless coding can trigger audits or retroactive payment demands. This risk was illustrated by the experience of practices facing six-figure clawbacks from Medicaid—a loss often reduced by careful chart audits and appeals. Dr. Lander advises never to immediately pay demanded refunds without review, as payors are often mistaken. He also recommends that physicians—not billers—select CPT codes, since only clinicians fully understand the nuanced care delivered. Regular internal audits and vigilance over payment accuracy protect practices from costly errors and unjustified takebacks.
Dr. Lander reviewed the basics of coding visits—for example, distinguishing new vs. established patients (new being anyone not seen in the last three years by any provider in the group/practice), and the use of specific codes for procedures done at the same time as visit codes. He addressed the use of modifiers such as -25 (for significant, separately identifiable E/M service on the same day), -76 (repeat procedure by same doctor), -77 (repeat procedure by a different doctor), and -22 (increased procedural services due to extraordinary effort). Knowing when and how to deploy these modifiers is critical, as misuse can trigger denials or audits, but proper use can significantly improve revenue.
Chart documentation has become even more essential under recent coding changes. As of 2023, the evaluation and management (E/M) code level is determined by components such as data reviewed, risk factors, and the number/complexity of problems addressed—rather than strictly by history and physical points. Time-based coding is also allowed, but only if total face-to-face and related care time is clearly documented for the date of service. Social determinants of health can now factor into coding but must be explicitly assessed and documented through standardized tools.
Dr. Lander also dispelled common myths, such as whether a rapid strep test done in the office “counts” as data when used for both coding and billing, and clarified how coding should work for telephone calls, nurse visits, and scenarios like coverage for another clinician’s patient or a practice under a different tax ID. He repeatedly stressed the value of persistent appeals and negotiation with insurers, both individually and collectively, as in his example of reversing an insurer’s drastic fee cut after coordinated chapter-level action.
He also pointed out that CPT and ICD books must be replaced yearly; relying on outdated codes leaves practices vulnerable to denials and underpayments. Training and continued education, preferably by physician-coders, are key. Misleading or outdated coding advice can lead practices into legal trouble or substantial financial loss, making it imperative to rely on reputable, clinically informed resources.
Proper utilization of CPT codes for ancillary services and procedures—such as developmental screening, vaccination, and asthma management—can be easily overlooked but represent substantial, legitimate reimbursement opportunities. Little-known add-on codes, such as for after-hours care or immediate attention for emergencies, can further support revenue if used and documented properly.
**Practical Takeaways for Pediatric Practices**
1. **Review Your CPT and ICD Codes Annually:** Each year, both sets of codes are updated. Replace your books and retrain staff to prevent denials or compliance issues due to outdated codes.
2. **Always Match Documentation to Coding:** Whether coding by complexity, data reviewed, or time spent, your notes must clearly justify the E/M level selected—and modifiers used. Do not neglect time documentation if using time-based codes.
3. **Monitor Payments and Appeal Errors:** Routinely audit EOBs to catch underpayments or breaches in contracted rates. Appeal any denials or reductions, and never pay large refund demands without a thorough, documented review.
4. **Use Modifiers and Add-on Codes Correctly:** Learn when to use -25, -76, -77, -22, and others for legitimate extra work, repeat procedures, or additive visits/procedures. Proper use can boost revenue; misuse can invite audit risk.
5. **Pursue Ongoing Coding Education from Physician-Coders:** Attend workshops and webinars from reputable organizations. Be wary of expensive programs with questionable accuracy—stick to resources affiliated with national specialty societies or trusted physician educators so your coding evolves with clinical and regulatory changes.
By applying these lessons, pediatric practices can not only safeguard against costly errors and audits but can also claim their rightful reimbursement for the essential care they provide. Effective CPT coding is more than paperwork—it is a core clinical and financial skill for every modern physician.