Specialties
Pediatrics Billing Services
A pediatric practice bills mostly prevention: well-child visits by age, immunizations with their own administration and product codes, and standardized screenings at set ages. Many patients are covered by Medicaid or CHIP, many vaccines come from the Vaccines for Children program, and the person responsible for the bill is never the patient.
- Preventive codes matched to the child's age band and new or established status
- Vaccine counseling and administration billed per component where allowed
- VFC vaccines billed for administration only, never for the product
Well-child visits are billed by age band
Preventive visits for children use their own code family, chosen by the child's age and whether they are a new or established patient: under one year, one to four, five to eleven, and twelve to seventeen. The code covers the age-appropriate history, exam, counseling and anticipatory guidance, so screenings and vaccines given at the visit are billed on top of it.
Medicaid is a large payer in most pediatric practices, and for children under 21 it includes the EPSDT benefit, which covers screening at set intervals and the follow-up care those screenings identify. Each state sets its own periodicity schedule and claim requirements for EPSDT visits, which we follow from the state Medicaid manual.
When a child comes in for a well visit and the provider also treats a new problem, such as an ear infection, a problem-oriented visit can be billed alongside the preventive code with modifier 25, if the problem required significant extra work that is documented separately. Minor problems handled within the preventive visit are already included.
Official source: Medicaid.gov: Early and Periodic Screening, Diagnostic, and Treatment (external site)
Vaccine administration: counseling and non-counseling codes
Vaccine claims have two parts: the product and its administration. Which administration codes apply depends on the child's age and whether the physician or other qualified provider counseled the family about each vaccine.
| Code set | When it applies | How it is counted |
|---|---|---|
| 90460, 90461 | Patients through 18 years when the physician or qualified provider counsels on each vaccine. | 90460 for the first component of each vaccine, 90461 for each additional component. |
| 90471 to 90474 | Administration without qualifying counseling, and patients 19 and older. | Counted per vaccine by route: injection, or intranasal and oral. |
| Vaccine product codes (906xx and 907xx) | The vaccine product itself, for privately purchased stock. | Not billed for a charge when the dose came from VFC. We follow the state Medicaid manual for how the product line is reported. |
VFC covers vaccines for eligible children 18 and younger, such as those enrolled in Medicaid, uninsured, American Indian or Alaska Native, and underinsured children at certain clinics. Medicaid sets the administration fee it pays for VFC doses, which varies by state; we track the current rate.
Official source: CDC: About the Vaccines for Children program (external site)
Pediatric preventive, screening and newborn codes
Codes that appear on most pediatric claims. Check the current CPT code set and your state Medicaid manual.
| Codes | Service | Billing notes |
|---|---|---|
| 99381 to 99384 | New patient preventive visits: under 1, 1 to 4, 5 to 11 and 12 to 17 years. | The code follows the child's age on the date of service. |
| 99391 to 99394 | Established patient preventive visits in the same age bands. | Billed with screening and vaccine codes as separate lines. |
| 96110 | Developmental screening with a standardized instrument, scored and documented. | Billed per instrument; the tool used and its result must be in the note. |
| 96127 | Brief emotional or behavioral assessment, such as depression or ADHD screening, per standardized instrument. | Units equal the number of instruments administered. |
| 96161 | Caregiver-focused health risk assessment, such as maternal depression screening at infant visits. | Billed under the child's claim because it is done for the child's benefit. |
| 99460 to 99463 | Newborn care in the hospital or birthing center, at other sites, subsequent days, and same-day admission and discharge. | For practices that round on newborns. |
CPT is a registered trademark of the American Medical Association.
Official sources: CMS: CMS-416 EPSDT reporting instructions (preventive and newborn codes) (external site), CMS NCCI Policy Manual, chapter 11 (immunization administration) (external site), CMS Medicare Coverage Database: article A52866 (developmental screening) (external site), CMS Medicare Coverage Database: article A57481 (brief behavioral assessment) (external site), CMS Medicare Coverage Database: article A59036 (caregiver health risk assessment) (external site)
Keeping vaccine and well-visit claims clean
Step 1: Check age and coverage at scheduling
Date of birth, Medicaid or CHIP status and VFC eligibility are confirmed before the visit.
Step 2: Separate VFC and private stock
Vaccines are tracked by source so VFC doses are billed for administration only and private stock is billed for product and administration.
Step 3: Match screenings to the schedule
Screenings due at each age are compared with what was documented and billed.
Step 4: Confirm who is responsible
Guarantor, primary plan and any custody arrangements are recorded before the first statement goes out.
Pediatric claims that need rework
Age band does not match the date of birth
A child who just turned five billed with the 1-to-4 code, or a demographic error in the birth date.
VFC vaccine billed as purchased stock
A charge for the vaccine product when it came from VFC supply, which Medicaid rejects and auditors flag.
Counseling codes used when counseling was not documented
Component-based administration codes billed without the provider counseling documented for each vaccine.
Screening billed without the instrument
Developmental or behavioral screens with no named tool or score in the note.
Wrong parent's plan billed first
Dual coverage through both parents sent to the wrong primary plan.
Sick visit with no separate documentation
Modifier 25 added to a minor problem that was handled within the well visit.
Which parent's plan pays?
When a child is covered by both parents, the plans' coordination of benefits rules decide which pays first, and a court order on health coverage can change the answer. The denial usually starts at the front desk: only one plan is recorded, or only the plan of the parent at the visit, so the claim goes to the secondary plan first and is rejected or later recouped. We ask about every plan the child is on at registration, record which one each plan treats as primary, and keep any custody or coverage order on file.
The guarantor, the adult responsible for the bill, may also differ from the plan subscriber. Recording both at registration, along with any custody paperwork the family provides, prevents statements going to the wrong household and claims going to the wrong plan.
Frequently asked questions
When can we bill a sick visit on the same day as a well-child check?
When the provider addresses a problem that needs significant, separately documented work beyond the preventive visit, the problem visit is billed with modifier 25. A minor issue handled within the well visit is included in the preventive code.
Should we use 90460 or 90471 for vaccines?
90460 and 90461 apply to patients through 18 when the physician or qualified provider counsels the family on each vaccine. Without that counseling, or for adults, 90471 to 90474 apply.
How do we bill vaccines from the Vaccines for Children program?
Bill the administration only. The vaccine product was supplied free, so it is reported without a charge, following your state's rules for the product line, and Medicaid pays the administration fee at the rate it sets.
Official source: CDC: About the Vaccines for Children program (external site)
Can developmental and depression screenings be billed at a well visit?
Yes, when a standardized instrument is used and scored, and the tool and result are documented. Each instrument is billed with its screening code in addition to the preventive visit.
Who do we bill when parents share custody?
Bill the plan that is primary under the plans' coordination of benefits rules or a court order on coverage, and send statements to the guarantor recorded at registration. If parents disagree, the order and the plans' rules decide, not the parent who brought the child in.
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Make every well visit and vaccine count
A free audit checks preventive age bands, vaccine administration and VFC billing, and screening codes across your pediatric claims.