Pediatrics CPT Codes and the ASC Referral Pathway
Pediatrics sits at the front of the ambulatory surgery pathway, not inside the operating room. The pediatrician evaluates the child in the office, identifies a condition that may need a procedure, and refers to a surgeon or proceduralist in an ASC or hospital outpatient setting. Most pediatric billing happens in the clinic under office E&M codes, 99202 through 99215, such as 99203 (new patient, low complexity) or 99214 (established patient, moderate).
The surgical CPT performed at the center is billed by the facility and operating surgeon, not the referring pediatrician, so the pediatric office E&M stays a separate claim. DataLily's procedure library tracks CPT-specific prior authorization and documentation requirements, helping the surgical side confirm what a pediatric referral needs before the date of service.
Pediatrics codes(9)
- 99213Office/outpatient visit, established patient, low (20-29 min)
- 99214Office/outpatient visit, established patient, moderate (30-39 min)
- 99204Office/outpatient visit, new patient, moderate MDM (45-59 min)
- 99202Office/outpatient visit, new patient, straightforward MDM (15-29 min)
- 99203Office/outpatient visit, new patient, low MDM (30-44 min)
- 99205Office/outpatient visit, new patient, high MDM (60-74 min)
- 99211Office/outpatient visit, established patient, minimal
- 99212Office/outpatient visit, established patient, straightforward (10-19 min)
- 99215Office/outpatient visit, established patient, high (40-54 min)
Are pediatric procedures performed in an ASC?
Many common pediatric surgical procedures are performed in ambulatory surgery centers when the child is an appropriate outpatient candidate. The pediatrician's role is usually to evaluate and refer rather than to operate. Whether Medicare or a payer covers a specific procedure in an ASC depends on its place on the CMS addenda, with Addendum AA codes being on the ASC Covered Procedures List and Addendum EE codes excluded from ASC payment.
What CPT codes does pediatrics use in this context?
In the ASC referral pathway, pediatrics primarily uses office evaluation and management codes 99202 through 99215. New patient visits are reported with codes such as 99202 and 99203, and established patient visits with 99213 and 99214. The surgical CPT codes themselves are reported by the surgeon and facility, not by the referring pediatric office.
What place of service applies to a pediatric office visit?
A pediatric office visit is reported with place of service 11, the office setting. That differs from the surgery center claim, which uses the ASC place of service. The two should be kept on separate claims so each provider and facility is reimbursed for its own part of the episode.