10 CPT Codes You’re Most Likely Under-utilizing

I found myself sitting next to four pediatricians during the hospital’s pediatric departmental meeting. The four docs were engaged in conversation by the time I sat down at the round table.

They were talking about coding. Specifically about 99213 and 99214. “Do any of you bill level 4s?” asked the one sitting across me. ” I can’t remember the last time I coded a level 4. I just don’t have that many emergencies,” replied the doc next to me.

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The pediatrician that sat across from me followed up in a justifying manner stating, “I keep it simple… level 3 all across the board. I don’t want to raise any red flags with the insurance companies.”

Judging by their nods, all four pediatricians seemed to agree.

Except for me, of course. But I couldn’t say anything because I was recovering from the feeling you get when somebody scratches their nails across a chalkboard.

You’d be hard press to find a cardiologist or orthopedist say; I keep my coding simple so that I can stay under the radar. But pediatricians are, well, pediatricians. And because of who they are and what they do, they are notorious for under-coding (most of them).

But that doesn’t mean we should give up on pediatricians. If anything, we should be motivated to work extra hard to get the word out on proper coding.

Below I’ve highlighted commonly underutilized codes in pediatrics; including level 4 and yes, level 5 (did you even know there was a level five?) in the hopes you or your staff will become aware of these codes and remember to use them.


According to the AAP, 99214 and 99215 (established patient office or other outpatient services) represent only 20% and 5%, respectively, of all evaluation and management codes submitted in pediatric claims.

What does this mean? That most pediatricians don’t code/bill for level 4 or 5s despite having done the appropriate work.

Don’t be afraid of coding level 4 and 5s. If you follow the requirements set forth by CPT and document the chart accordingly, you’ll realize levels 4 and 5 reflect your work with the patient more than a level 3.


If so, you can bill for consult codes 99241, 99242, 99243, 99244, and 99245 ( office or other outpatient consultations)

You may overlook consult codes because pediatricians are not specialist. However, a surgeon, for example -with all their specialized training – won’t even give a kid Tylenol without clearance from their primary doctor. Thus, pediatricians are indeed consultants.

There are a few requirements to bill this code. For example, follow-up with the requesting physician (i.e., the surgeon) with a written report or a hospital’s standard pre-op form.


As the doctor places her hand on the doorknob after completing an exhausting well-visit, she ask the parent, “…is there anything else?”

The phrase, is there anything else? is doctor code for, we’re all done here, I got to go. For the parent, it’s an invitation, of course. What else would it be?

“There is,” says the mom. ”

If you decide to address the issue right then and not ask the parent to come back, you are performing two significant, separately identifiable evaluation, and management services during the course of a single visit.

Therefore, you should attach modifier 25 to the office or other outpatient service code and list that in addition to the preventive medicine service code.

An example of this is preventive medicine service with an acute swimmers’ ear.The preventive medicine service may be linked to Z00.129 while the office or other outpatient service may be linked to H60.339 (swimmer’s ear, unspecified ear).


Do you see patients on a scheduled holiday? Do you see patients late into the evening? How about on Sundays? Do you see patients on Sundays? If you answered yes to any of these questions, you could code 99051 for every visit in addition to the E&M code.

CPT defines this code as service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic services.


Nursemaid’s elbow is a common occurrence in the pediatric population. Do you know that you can code for the treatment of it?

Code 24640 (closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation) may be reported as well as an evaluation and management code if a significant, separately identifiable evaluation and management service is provided.

If this is the case, attach the modifier 57 (decision for surgery) or the modifier 25 (significant, separately identifiable E/M service) to the associated evaluation and management code.


Case management is a process whereby a physician is responsible for direct care of a patient and for coordinating and controlling access to or initiating and/or supervising other health care services needed by the patient.

Sounds complicated. But it isn’t.

Do you spend time on the phone with parents? How about emails or portal messaging?

If you spend a lot of time communicating with parents, either on the phone, email, portal or phone app, you can bill for case management codes.

Although the chances the practice will receive payment for these codes is slim, coding experts and practice management consultants insists it is still a good idea to bill for what you do.

Therefore, whether you communicate with the patient via phone (99441-99443 or e-mail 99444), you are providing care for the patient and should bill for your services.


Let’s say a mom brings her daughter in because she suspects she is a victim of child abuse.

According to the APP, the pediatrician is required to perform a complete evaluation and management service in addition to an anogenital exam with colposcopic magnification.

With an example like this one, you should report both the evaluation and management service and the colposcopy. For the anogenital exam, use code 99170.

Don’t forget to add modifier 25 to the evaluation and management code to “alert” the insurance processing the claim the fact that you performed a significant, separately identifiable evaluation, and management service in addition to the colposcopy during a single visit


Have you received a call from a parent at the end of the day asking if her child can be seen? And because you can’t bare the thought of the child suffering for another 12 hours or feel guilty telling the parent to go to the ER, you and a few staff members end up staying after regular office hours to see the child?

If it has happened to you, make sure that you are billing for 99050 in addition to the E&M code

This code is for services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed.


Imagine for a moment that instead of a mom calling your office at the end of the day, she shows up mid-morning with a wheezing kid.

Do you see that patient right away, essentially on a “walk-in” basis and make all other patients wait?

If you do, you should be billing for “service(s) provided on an emergency basis in the office, which disrupts other scheduled office services” (99058) in addition to the evaluation and management code.


Do you screen or ask parents to complete forms that aid in the assessments of a child’s development? For example, manage developmental screening tools such as Developmental Screening Test II, Early Language Milestone Screen, PEDS, Ages and Stages, and Vanderbilt ADHD rating scales?

If so, you should be reporting it using CPT code 96110 (developmental testing; limited) or 96127 (brief emotional/behavioral assessment)

Keep in mind that the purpose of this post is to bring to your attention a handful of codes that pediatricians don’t use as often as they should. I’d suggest finding coding and billing resources that go in depth into each of the codes supplied in this post, as well as provide a plethora of other underutilized code.


  1. Great article, but Vanderbilts/PHQ should be billed with a 96127, not 96110.