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4 Pitfalls to Avoid in the Pediatric Therapy Claims Process

The claims process can be a constant source of frustration for pediatric therapy clinics. If a claim is delayed or denied, the clinic won’t get paid in a timely manner — and may not get paid at all. Cash flow suffers, ultimately impacting the clinic’s success.

Billers are dealing with complex coding systems and complicated forms, so it’s easy for mistakes to happen. Staying alert for the most common errors will reduce mistakes and increase the percentage of claims that make it through smoothly. In this post, we’ll explore four top pitfalls to watch out for in the pediatric therapy claims process.

What’s the Difference Between a Delayed and Denied Claim?

First, let’s define the difference between delayed (termed “rejected”) claims and denied claims.

If a claim is denied, a payer has determined that it’s unpayable due to errors, missing information, or the patient’s coverage limitations. The payer will attach an explanation to the returned claim that outlines the problem. All is not lost if your claim is denied, however. Depending on the reason for denial, you can appeal it and reprocess the claim.

Claims that are delayed or rejected are easier to deal with. These claims usually have simple mistakes that you can correct, and then you can resubmit the claim. Processing is much quicker for resubmitted claims than for appealed claims.

1. Forgetting to Gather Signatures Before Starting Service

Time flies, especially when you’re on a deadline. But if you fail to get the prescribing physician’s signature on a plan of care before starting treatment, Medicare may deny the claim, assess an error, and/or begin recouping overpayments. Signatures can be electronic, so implementing technology that allows you to make this process paperless will speed things up.

ASHA offers a robust checklist to avoid this and other mistakes on the CMS-500 form.

2. Failure to Double-Check Your Codes

Billing codes are notoriously complex and not always straightforward. For this reason, coding is part art, part science. And it’s the easiest place to make mistakes resulting in delays or denials.

ICD-10 Codes — The ICD-10 coding system was designed to more accurately and specifically describe diagnoses than the ICD-9 system it replaced. Many codes (though not all) were made more specific by adding a seventh character to them. If you aren’t using a specific ICD-10 code when you should be, you could run into problems. A good EMR will prompt you to enter more specific codes when appropriate. 

Modifier 59 — If two services are commonly provided together, payers will reimburse as if they were provided simultaneously. If you administered the services separately, you’ll need to use Modifier 59 on one of the codes to be reimbursed properly.

Learn more about Modifier 59 and ensure you’re using it correctly with our Modifier 59 Checklist that is included in our free resource library.

Code 97110 — Code 97110 is popular because it covers so many types of services. But it doesn’t pay out as highly as some other codes, such as those for services that include use of equipment. So if the services you’re providing should actually be using different codes, you’re leaving money on the table, and you could trigger an audit.

3. Not Tracking Your Time for Time-Based Procedures

Service-based procedures are reimbursed per service, regardless of how much time is spent. But time-based procedures are billed in time increments. If you aren’t tracking all the time spent with a patient, you won’t be able to bill for what you’re actually providing.

Time tracking isn’t a part of the job that a therapist enjoys, but it’s essential for proper reimbursements. Any time you spend providing skilled work with a patient can and should be billed.

4. Entering Incorrect Information

This error is the easiest to avoid. But because billers are only human, mistakes sometimes happen when entering information on a claims form. Pay particular attention to the following.

One good way to avoid error is to use an automated EMR system to handle the process digitally. For example, a good EMR will automatically generate claims based on services or appointments, populating the CMS 1500 form with existing documentation and patient data. Your EMR should also have a claim scrubbing feature that will help check for accuracy.

The claims process is cumbersome by nature. Because billing rules and regulations are continually changing, billers have their hands full keeping up with compliance. But watching out for these four pitfalls will help you avoid common mistakes and improve your track record of approved claims.

Disclaimer: Billing rules and regulations are continually changing, so be sure to check with Medicare and your industry organizations for the most up-to-date information. While we try to do our best to provide accurate information, you should always check with official rules and regulations.

Need help with billing? Let us take care of your claims.


Spend less time on billing with Fusion’s claims management service. Schedule a call to find out if Assisted Billing is a good fit for your practice.

Coverage & Benefits Verification Questionnaire

We’ve created this printable questionnaire to help you remember what you need to ask when you’re verifying coverage. We hope it helps you spend less time on the phone with payers!