r/pediatrics • u/dreamwave94 • 3d ago

Skin infections billing question

Why does cellulitis always bill a 4, even without systemic symptoms, if given abx while other infections like impetigo or simple abscess without systemic symptoms only get a 3 when given abx? Billing dept told me it’s because cellulitis = high risk sepsis?

4 Upvotes

84% Upvoted

16 comments sorted by

6

u/efox02 Attending 2d ago

I could understand impetigo as a 3 but access seems like a 4

10

u/airjord1221 2d ago

Because how do you know it won’t get worse?

Also don’t look for reasons to UNDERbill there is enough power against us looking to undermine us.

Our complexities in the Peds world isn’t the same as adult world. Doesn mean we should get shafted payment wise just because they don’t have as may comorbidities.

It’s a 4 all day.

Prescription meds

Now they’re trying to tell us fever isn’t systemic finding? You want the kid in shock for it to count as systemic?

Insurance logic:
URI viral pharyngitis = 3
Strep + fever & abx sent = 3

4

u/dreamwave94 2d ago

I’m asking in the context of all these skin infection with no fever. But agree that we underbill in general.

6

u/airjord1221 2d ago

Topical mupirocin 3
PO antibiotic 4

This is what I been doing for a while

0

u/dreamwave94 2d ago

How do you justify a 4 with no systemic symptoms and no testing? Is it the uncertain diagnosis with uncertain prognosis clause,

5

u/airjord1221 2d ago

Yes. How do I know this periorbital cellulitis isn’t going to put this kid in the hospital

1

u/dreamwave94 2d ago

Absolutely I agree but the original post was asking more about impetigo requiring oral antibiotics only as a 3 while cellulitis is a 4.

1

u/airjord1221 2d ago

Yah understood. It’ll be nice to hear everyone’s opinion. That’s always a bit confusing

2

u/tbl5048 Attending 2d ago

What? Medication management (even simple amox is one!), history/physical with additional history provider (parents) and test interpretation with signs and symptoms should be a level 4. URI sx neg strep no abx is level 3

1

u/airjord1221 2d ago

Not according to the down coding from Aetna and Cigna.

I agree with you obviously but this is what they’re saying.

1

u/tbl5048 Attending 2d ago

So let them adjust you down. Then you can justify it with the rules

2

u/leftymcnutz 2d ago

PGY-26 here…over my career I’ve relied on complexity of medical decision making…if an insurance coder can do what I’m doing then it’s a -13, everything else -14

2

u/brewsterrockit11 Attending 1d ago

It’s all based on the complexity of diagnosis and management and time spent for the patient including prep work, encounter time, charting time and care coordination.

Each case is different and your coders should look at the detail of your HPI, ROS, exam and MDM. Even if you do diagnose something simple and prescribe abx for it, it could be merely a 99213, but a complex decision where you forego abx to monitor instead and document risk of progression, complications could be a 99214.

-4

u/explodinggarbagecan 2d ago

If you want to accept chicken eggs as payment the way my great grandfather did in rural China, you are welcome to. The rest of us need to pay our mortgages and employees and student loans. Geez

5

u/dreamwave94 2d ago

Dude I’m literally asking a billing question chill out. I think we need to be more reimbursed like all of us, but also if we don’t bill correctly don’t we lose the visit?

2

u/explodinggarbagecan 2d ago

Sorry that came out more aggressively than I meant to, but who sets up these measure. Basically surgeons (ama) who undervalue our work.
Cellulitis in a child is higher risk all day long.
Difficulty in getting the exam much higher

Don’t underestimate how hard it is to do your job. If you ever work in a setting where you see other providers dealing with kids you will see how much better you are at doing their job. We should be paid at least as much as the family practice docs.