Pediatric Billing — Well-Child to Specialty, Covered

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

Proven Results

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.

Comprehensive Immunization Billing

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

Preventive Care Optimization

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

Real-Time Eligibility Verification

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

Specialized Services

Well-Child Visit Billing

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

Immunization Services

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

Sick Visit & Acute Care

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

Specialty Pediatric Services

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

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.

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.

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.

Payer-Specific Billing Tips

Medicaid (EPSDT)

Medicare (Rare for Children)

Commercial Payers

Pediatric Billing Best Practices

Related Billing Resources

Key Services

Contact Medtransic today for expert pediatric billing billing services. Call 888-777-0860 or visit https://medtransic.com/contact for a free consultation.