Pediatric billing has unique age-based coding and vaccine administration rules. Our specialists handle well-child visits, immunizations, and pediatric procedures with expert precision.

Common Billing Challenges

Age-Based Coding Complexity

Pediatric billing requires age-specific CPT codes and modifiers for accurate reimbursement across different developmental stages.

Immunization Billing Challenges

Complex vaccine billing with multiple components including administration, counseling, and product codes.

Preventive vs Sick Visit Coding

Distinguishing between well-child visits and sick visits while properly billing for both on the same day.

High Volume, Lower Reimbursement

Pediatric practices handle high patient volumes with lower per-visit reimbursements, requiring efficient billing processes.

Missed Preventive Service Revenue

Failure to capture all billable preventive services including developmental screening and anticipatory guidance.

Multiple Payer Policies

Different insurance policies for pediatric services including CHIP, Medicaid, and commercial payers with varying requirements.

Our Solutions

Pediatric-Certified Coding Team

Our specialized coders understand age-specific requirements and pediatric coding nuances for accurate billing.

Expertise in age-based CPT code selection
Proper use of pediatric modifiers
Knowledge of developmental milestone coding
Reduced coding errors and claim rejections

Comprehensive Immunization Billing

Complete vaccine billing capturing administration, counseling, and product codes for maximum reimbursement.

Accurate vaccine product and administration coding
Proper counseling code application
VFC program compliance
Maximized immunization revenue

Preventive Care Optimization

Ensure all well-child visits and preventive services are properly documented and billed for optimal revenue.

Complete well-child visit billing
Developmental screening capture
Anticipatory guidance coding
Improved preventive care revenue

Real-Time Eligibility Verification

Advanced technology verifies insurance eligibility before appointments to reduce claim denials and patient issues.

Instant insurance verification
CHIP and Medicaid eligibility checks
Reduced claim denials
Improved patient satisfaction

Specialized Services

Well-Child Visit Billing

Complete billing for preventive checkups with age-appropriate screening and counseling codes.

Age-specific preventive codes
Developmental screening
Anticipatory guidance
Vision/hearing screening

Immunization Services

Comprehensive vaccine billing including administration, counseling, and VFC program compliance.

Vaccine administration codes
Counseling documentation
VFC program billing
Multi-vaccine visits

Sick Visit & Acute Care

Accurate billing for illness visits, same-day preventive and sick visits, and urgent care services.

E/M code optimization
Same-day visit billing
Modifier 25 application
Procedure coding

Specialty Pediatric Services

Billing for subspecialty services including asthma management, ADHD treatment, and chronic condition care.

Chronic care management
Behavioral health integration
Asthma care billing
Special needs services

Common CPT Codes Reference

Key codes include 99381 (Preventive care, new patient, under 1 year), 99382 (Preventive care, new patient, 1–4 years), 99383 (Preventive care, new patient, 5–11 years), 99391 (Preventive care, established patient, under 1 year), 99392 (Preventive care, established patient, 1–4 years), 99393 (Preventive care, established patient, 5–11 years), 99394 (Preventive care, established patient, 12–17 years), 90460 (Immunization administration, first vaccine component, throug), 90461 (Immunization administration, each additional component), 99213 (Office visit, established patient, 20–29 min). Proper code selection requires understanding of bundling rules, NCCI edits, and modifier usage.

Expert Billing Insights

Well-Child Visit Billing: EPSDT, Vaccines, and Separate Sick Visit Rules

Well-child visits (preventive E/M codes 99381–99397) are among the most heavily regulated billing scenarios in pediatrics. EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) under Medicaid mandates comprehensive preventive services for children — more broadly than standard preventive care. When a sick visit is also addressed on the same date as a well-child visit, modifier 25 must be used on the sick visit E/M code. Immunization administration during well-child visits uses the pediatric-specific administration codes (90460/90461) that are higher than adult administration codes.

Modifier 25 required when billing both well-child (99381–99397) and sick visit on same date
90460: pediatric immunization admin with counseling — requires physician counseling documentation
EPSDT screenings (vision, hearing, lead, development) included in well-child — document each performed
VFC (Vaccines for Children) program: vaccines free to eligible children — only bill admin code

Developmental Screening and Autism Billing

Developmental screening tools (M-CHAT-R/F, Ages & Stages, PEDS) are separately billable with 96110 when performed and scored during well-child visits. Positive screens that lead to formal developmental testing and autism evaluation create additional billing opportunities using neuropsychological testing codes. Early autism diagnosis creates EPSDT-covered entitlement to behavioral health services (ABA, OT, SLP) — billing these services appropriately requires understanding each payer's autism benefit structure.

96110: developmental screening tool with physician scoring and parent counseling — billable at well-child
Formal autism evaluation: 96112/96113 (developmental test administration) + 96130/96131 (psychological testing)
ABA therapy: covered under Medicaid EPSDT; commercial autism mandates vary by state
Document developmental milestones met and missed at every well-child visit

Newborn and Neonatal Billing: Hospital, Nursery, and NICU Codes

Newborn billing requires understanding nursery codes (99460–99463) for normal newborns and neonatal intensive care codes (99468–99480) for complex cases. The attending or covering pediatrician bills for all normal newborn assessments during the birth hospitalization. The first examination after birth uses 99460 (initial newborn care) and subsequent days use 99462 (subsequent normal newborn care). Discharge from normal nursery uses 99463 if same-day admit/discharge, or 99238/99239 after 30 days of age.

99460: initial newborn care in hospital; 99462: subsequent newborn care; 99463: same-day discharge
Neonatal intensive care (NICU): 99468 (initial, ≤28 days); 99469 (subsequent, ≤28 days)
Newborn circumcision: 54150 (with clamp); billed separately from newborn care codes
Attending bills for newborn even if resident or hospitalist also involved — verify billing privileges

Payer-Specific Billing Tips

Medicaid (EPSDT)

EPSDT covers comprehensive preventive care for all Medicaid-enrolled children through age 21
EPSDT: all medically necessary screening, diagnosis, and treatment must be covered — even if not in state plan
Vaccines: VFC program covers immunization cost; bill 90460/90461 for administration only
ABA therapy, OT, SLP, and DME covered under EPSDT for autism — file to Medicaid with ASD diagnosis

Medicare (Rare for Children)

Medicare enrollment is rare for children except those with ESRD or certain disabilities
Disabled children on SSI may have Medicare Part A and B after 24-month waiting period
CHIP (Children's Health Insurance Program): separate from Medicaid, similar EPSDT coverage
Transition-age youth (18–26) may shift to commercial parent plan under ACA dependent coverage rules

Commercial Payers

ACA mandates coverage of all ACIP-recommended vaccines for children at no cost-share
Well-child visits (ACIP schedule): zero cost-share for preventive services under ACA plans
Separate sick visit billing on well-child day: modifier 25 required to avoid denial
Developmental and autism evaluations: coverage varies; state autism mandates affect benefit levels

Pediatric Billing Best Practices

Lead and hemoglobin screening at 9–12 months and 24 months: separately billable with HCPCS
Fluoride varnish application: D1206 — dental code, but increasingly covered by medical plans
School and sports physicals: bill as preventive E/M (99385–99387) — not as sick visit
Adolescent consent laws: some states allow minors to self-consent for STI, pregnancy, mental health

Pediatric Billing — Well-Child to Specialty, Covered

Proven Results