Pediatric Billing Services
Expert billing for pediatric practices with deep expertise in well-child visits, vaccine administration, EPSDT billing, and the complex Medicaid requirements unique to pediatric medicine.
Pediatric Revenue Optimization
Specialized billing for children's health practices nationwide
Why Pediatric Billing Requires Specialized Knowledge
Pediatric billing operates under significantly different rules than adult medicine. While other specialties focus on treating disease, pediatrics centers on preventive care—well-child visits, developmental screening, and immunizations. These preventive services have unique coding requirements, specific Medicaid (EPSDT) rules, and vaccine billing complexities that general medical billers simply don't understand.
The vaccine billing challenge alone trips up most practices. A single well-child visit can involve 5-7 different vaccines, each requiring both an administration code and a product code. Miss one component, and you've left $150-200 on the table. Multiply that by 50 well-child visits per week, and you're losing $7,500-10,000 weekly—nearly $400k annually—just from vaccine billing errors.
Medicaid's EPSDT (Early and Periodic Screening, Diagnostic and Treatment) program has its own unique billing requirements that vary by state. EPSDT visits require specific procedure codes, particular documentation elements, and careful tracking of periodicity schedules. Many states have supplemental payment programs for comprehensive EPSDT services that practices don't even know exist—leaving significant money uncollected.
We built our pediatric billing practice specifically to capture these specialty-specific revenue streams. Our team understands the difference between preventive and sick visit codes, knows which vaccines can be billed together, and tracks state-specific Medicaid rules that impact your reimbursement.
Pediatric Billing Expertise Built for Children's Health
Vaccine Billing Mastery
Complete capture of vaccine administration codes (90460, 90461, 90471-90474) paired with correct vaccine product codes. We handle combination vaccines, multiple injections same day, and age-appropriate billing.
Well-Child Visit Optimization
Proper use of preventive visit codes (99381-99385, 99391-99395) based on patient age. Correct modifier usage when preventive and sick visits occur same day. Bright Futures guidelines compliance.
EPSDT/Medicaid Expertise
State-specific EPSDT billing including proper diagnosis code sequencing, periodicity schedule tracking, and supplemental payment program enrollment. Medicaid denial prevention and appeal management.
Developmental Screening
Proper billing of developmental screening tools (96110, 96127), autism screening (96127), and depression screening (96127). Documentation requirements and age-appropriate billing intervals.
Sick Visit Management
Accurate diagnosis coding for common pediatric conditions. Proper level of service selection (99202-99215). Same-day sick and preventive visit billing with modifier 25 when appropriate.
Telehealth Pediatrics
Virtual visit coding for sick visits, behavioral health, and lactation support. State-specific telehealth policies for pediatrics. Proper modifier use and place of service coding.
Vaccine Billing: Getting Every Dollar You've Earned
Vaccine billing represents one of the biggest revenue opportunities—and revenue leaks—in pediatric practice. The complexity comes from the dual-code requirement: you must bill both the administration (giving the shot) and the product (the vaccine itself). Miss either component, and you've lost half your payment.
Administration codes vary by patient age and counseling. For patients through age 18, when face-to-face counseling occurs, use codes 90460 (first component) and 90461 (each additional component). A "component" is each antigen in the vaccine—so DTaP has 3 components (diphtheria, tetanus, pertussis). For no counseling or patients 19+, use 90471 (first injection) and 90472-90474 (additional injections/routes).
Vaccine product codes (90XXX series) must match exactly what was administered. Pediarix, Pentacel, and DTaP are all different products with different codes and different reimbursement. Brand name matters. Manufacturer matters. Using a generic code or the wrong specific code results in denials or underpayment.
Multiple vaccines same visit require careful documentation. When a child receives 5-7 vaccines in a well-child visit, each vaccine needs its own administration and product billing. The documentation must clearly show which vaccines were given, which sites were used, and any adverse reactions discussed. Incomplete documentation results in bundled payments or denials.
VFC (Vaccines for Children) program creates additional complexity. VFC-supplied vaccines can't have product charges billed to Medicaid, but administration can still be billed. We track VFC enrollment by payer and automatically suppress product billing when appropriate while ensuring administration charges are captured. For more on our systematic denial prevention approach, see our RCM Intelligence framework.
Pediatric CPT Codes & Reimbursement
Understanding typical reimbursement helps practices prioritize proper documentation. Here are common pediatric services with Medicare reimbursement rates (Medicaid rates vary by state, commercial rates typically 120-180% of Medicare).
Critical note on same-day billing: When a problem-oriented sick visit occurs during a well-child visit, both can be billed with modifier 25 on the sick visit E/M code (99202-99215). Documentation must clearly distinguish between the preventive service and the additional illness evaluation. Without proper modifier use, the sick visit gets denied as bundled with the preventive visit.
Pediatric Billing FAQs
How do I bill vaccines administered during a well-child visit?
Bill the preventive visit code (99381-99395) for the well-child exam, then separately bill vaccine administration codes (90460/90461 or 90471/90472) plus vaccine product codes (90XXX) for each vaccine given. All services are separately reimbursable. For patients through age 18 with face-to-face counseling, use 90460 for the first component and 90461 for each additional component (remember combination vaccines have multiple components—DTaP has 3, MMR has 3, etc.).
Can I bill for both a sick visit and well-child visit on the same day?
Yes, with proper documentation and modifier use. Bill the preventive visit code (99391-99395) for the well-child portion, then bill an appropriate E/M code (99202-99215) with modifier 25 for the sick visit evaluation. The documentation must clearly separate the two services—the routine preventive exam and history versus the problem-oriented evaluation of the illness. Without clear separation in documentation, payers will deny the sick visit as included in the preventive service.
What's the difference between 90460/90461 and 90471/90472?
Codes 90460/90461 are for vaccine administration to patients through age 18 when face-to-face physician counseling occurs, and they're billed by component (each antigen in the vaccine). Codes 90471/90472 are for administration with no counseling, or patients 19+, and they're billed by injection. Most pediatric practices use 90460/90461 because counseling is standard. The difference in reimbursement is significant—a DTaP vaccine (3 components) bills as 90460 + 90461 x2 versus just 90471 if no counseling documented.
How does VFC (Vaccines for Children) affect billing?
VFC-supplied vaccines cannot have product charges billed to Medicaid—the state already paid for the vaccine through VFC. However, administration charges (90460/90461) are still billable and reimbursable. For non-Medicaid patients receiving VFC vaccines (uninsured, underinsured), the administration can be billed to the patient or other insurance, but product charges cannot. We track VFC enrollment status by payer and automatically adjust billing to avoid compliance issues while ensuring you're paid for the administration service.
What is EPSDT billing and how is it different?
EPSDT (Early and Periodic Screening, Diagnostic and Treatment) is Medicaid's comprehensive preventive care program for children under 21. EPSDT visits require specific documentation including comprehensive health and developmental history, comprehensive physical exam, age-appropriate screening, and anticipatory guidance. Some states require specific EPSDT procedure codes or modifiers. Many states offer enhanced payments for comprehensive EPSDT services. We track state-specific EPSDT requirements and ensure proper code selection and documentation to maximize reimbursement while maintaining compliance.
Stop Losing Pediatric Revenue to Billing Errors
Incomplete vaccine billing and missed screening charges cost pediatric practices $35k-50k annually. Let's calculate your exact revenue gap.
Serving pediatric practices nationwide. Expert billing for well-child visits, vaccines, and EPSDT services.
A-Z Medical Billing & Consulting was founded by Zain Vally, who identified persistent revenue cycle inefficiencies while operating Vally Medical Group, a multi-location occupational medicine practice across Hawaii. The hands-on experience of managing billing operations for practices spanning multiple islands revealed systematic problems in how most billing services approach specialty-specific coding. Our pediatric billing expertise comes from years of working with children's health practices to master vaccine billing, EPSDT requirements, and the preventive care focus unique to pediatrics. We built A-Z specifically to address these gaps through systematic prevention, aggressive pursuit of denied claims, and transparent reporting.