So You Think You Can Code? A Pediatrician’s Guide to Smarter Coding

Let’s be honest. No one went into pediatrics because they love coding.

But here we are—navigating the ever-evolving landscape of CPTs, ICDs, and E&M codes every day.

Most of us learned about coding on the job: between patient visits, in hallway chats with colleagues, or from a billing department tip. And just when you think you’ve got it down, the rules change (hello, 2021 E&M update).

If you’ve ever second-guessed yourself about billing a 99213 versus a 99214—or worried you’re leaving money on the table by oversimplifying coding—you’re not alone.

That’s why we sat down with pediatrician and coding expert Dr. Richard Lander for a two-part Peds RAP podcast series to break it all down.

In this blog, we’ve pulled together the must-know info from Part 1, “Coding 101: Essential Guide to Getting Started.” Whether you’re just starting out and learning the ropes, or you’re a seasoned pediatrician running your own practice, there are helpful tips for everyone here.

The Basics: Coding 101

First, let’s start with a quick refresher on terms:

• ICD-10 codes = Diagnosis or symptoms (in other words, what’s going on with the patient)

• CPT codes = What you did during the visit (medical procedures, services)

• E&M codes = A subset of CPTs that is focused on office visits (like well and sick visits)

For routine preventative care, your E&M code will be based on age. Choosing the right E&M code for a sick visit is where it can get tricky. Many of us either undercode or second-guess ourselves.

For office visits, you pick your level based on:

• Total time spent on the day of the encounter or

• Medical Decision-Making (MDM)

Most of us use MDM. It’s based on three things:

1. 1. Problems: Number and complexity of problems addressed
2. 2. Data: Amount and/or complexity of data reviewed and analyzed
3. 3. Risk: Risk of complications and/or morbidity of patient management decisions

Each of these components has criteria to help determine if that category falls at a Level 2, 3, 4, or 5. To determine your overall visit code, you need to have 2 out of 3 categories at that level. And of course, this level affects the reimbursement from insurance companies or Medicare. 

The American Medical Association has a great chart to help you keep track of what it takes to reach each level for each category. Check out this graphic for detailed information. 

Pearls from the Podcast

Here are some of the points from the podcast that I found especially helpful to tease out the right level for a visit. 

Data

• If you get your information from a 3rd party—like a parent—you’re already at a level 3. So, pediatric encounters often meet the data criteria for a level 3 right off the bat. 

• If you’re following up a patient who went to the ED and you review bloodwork or an xray, this counts as “Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported)”, and that puts you at level 4 for data.

• If you talk to that ED physician about your patient, that can also put you at level 4. And if you talk to the outside physician AND review the ED labs/imaging, that puts you at a 5 for data.

Number and complexity of problems

• An acute otitis media without a fever would qualify as an “uncomplicated illness or injury” and would typically count as a level 3. But if the presentation includes fever or other systemic symptoms such as dehydration or fussiness, Dr. Lander advises that this qualifies as a level 4: “acute illness with systemic symptoms.” 

• If you evaluate a child who presents with fever and whose workup doesn’t identify the cause, this would count as a level 4. It would qualify as an “undiagnosed new problem with uncertain prognosis.”

• Similarly, if a child has abdominal pain and there’s no clear diagnosis, r/o appy is often still on the diagnosis, so depending on the other details, that could count as a level 4 for problems. 

• 2 chronic conditions—for example, eczema and asthma—count as a level 4. 

Risk

• Prescribing medication puts the encounter at a level 4. But so does discussing medication. So, that “watchful waiting approach” to AOM? Counts as a level 4 for risk even if they never use the medication. 

• A relatively new addition to the E/M coding system is “diagnosis or treatment significantly limited by social determinants.” For example, let’s say you diagnose iron deficiency anemia and then determine that the child is experiencing poverty that is affecting her nutritional status, that would reach a level 4 on risk

And always remember: documentation is key. If it’s not documented, it didn’t happen. 

Time-Based Coding: When Minutes Matter

If you spend a significant amount of time on a patient encounter, consider time-based coding. This is about more than face-to-face time. It’s based on the total time spent, which includes: 

• Pre-visit chart review

• Obtaining patient history and performing exam/evaluation

• Counseling

• Ordering tests, medications or procedures

• Referring and communicating with other healthcare professionals

• Documentation

• Independently interpreting results (not reported separately) and communicating results to the patient/family

Established patients:

99212 = 10 min

99213 = 20 min

99214 = 30 min

99215 = 40 min

New patients:

99202 = 15 min

99203 = 30 min

99204 = 45 min

99205 = 60 min

A few key highlights about time-based coding:

• Document the total time in your note. No need to break it down into sub-tasks—just the total time spent on the activities listed above.

• The clock starts and ends on the same calendar day. All activities must occur between 12:00 a.m. and 11:59 p.m. on the day of the encounter. This means that:

  • - Documenting your notes on the same day as the visit can help give you a boost when it comes to time-based coding. 

  • - Follow-up calls count towards time if they happen the same day. For example, if you call back families later in the day to discuss results—like a developmental screen or abnormal hemoglobin—that time can be included.

• Phone time with the pharmacy counts, too. Dr. Lander has folks who handle those calls. But for the rest of us? If you find yourself on a 7-minute hold clarifying medication dosing, that time can be added to the encounter. Every minute matters!

Final Pointers to Keep Your Coding Sharp

When it comes to mastering coding, it’s not just about knowing the right codes. Dr. Lander encourages pediatricians to keep these tips in mind:

• Document thoroughly. Strong documentation determines which code is valid—and defensible.

• Stay up to date. Sign up for the AAP Coding Newsletter or find other ways to stay in the loop on coding changes.

• Challenge denials. Don’t hesitate to appeal. Have a process for resubmitting claims, and consider using the AAP Coding Hotline and Hassle Factor Form if a well-documented visit is denied.

For more helpful tips, check out our February 2025 episode "Coding 101" podcast segment. And tune into our March 2025 episode, "Coding Mastery: What Every Pediatrician Needs to Know", where we go deeper into advanced strategies.

None of us went into pediatrics to become coding experts. But the better we get, the better we can advocate for the value of our work. Accurate, thoughtful coding ensures we’re fairly compensated for our time and expertise—so we can keep focusing on what matters most: caring for kids and connecting with families.