Pediatric Billing Services That Protect Your High-Volume Revenue

We manage the complete range of pediatric CPT codes including:

• 99381-99395 — Well-child visits (newborn through 17+ years)
• 99213-99215 — Sick/problem-oriented E/M visits
• 99431 — Initial newborn hospital care
• 99432-99433 — Subsequent newborn hospital care
• 90460 — Immunization administration, first vaccine (intramuscular/subcutaneous)
• 90461 — Each additional vaccine (same route)
• 90471-90474 — Immunization administration (without counseling)
• 90476-90749 — Vaccine product/toxoid codes
• 96110 — Developmental screening
• 69436 — Tympanostomy tube insertion
• 42820-42826 — Tonsillectomy and adenoidectomy

This is the most common pediatric billing error. When a child presents for a well-child visit (99391-99395) and the parent also mentions an acute issue (like an ear infection or rash), you can bill both the preventive visit and a separate sick E/M visit — but only if specific conditions are met. First, modifier 25 must be appended to the sick E/M code. Second, and critically, the documentation must clearly separate the preventive elements (growth, development, immunizations, anticipatory guidance) from the evaluation and management of the acute problem. If the note just says "well-child visit, also treated otitis media," the payer will bundle the sick visit into the well visit. Our team reviews every same-day combination to verify the documentation supports separate billing before the claim goes out.

Vaccine billing requires pairing two code types. First, the administration code: if the provider counsels the parent/guardian, you use 90460 for the first vaccine component and 90461 for each additional component given at the same visit. If no counseling is provided, you use 90471 for the first and 90472 for each additional. Second, the vaccine product code (90476-90749), which identifies the specific vaccine (e.g., 90698 for DTaP, 90716 for MMR). The administration code is based on the route and number of components, while the product code is based on the specific vaccine. We ensure the correct pairings every time, and we track product code reimbursements against your inventory costs to make sure you're recovering what you paid for the vaccines.

The Vaccines for Children (VFC) program provides free vaccines to children who are Medicaid-eligible, uninsured, underinsured, or Native American/Alaska Native. When you administer a VFC vaccine, you cannot bill the patient or the state for the cost of the vaccine product — but you CAN bill for the administration fee. The complexity is that billing rules vary significantly by state. Some states require you to use a specific VFC product code to identify it as state-supplied inventory. Others require you to bill the standard product code with a $0.00 or reduced fee. We understand your state's specific VFC billing requirements and ensure your claims are coded correctly to maximize your administration fee reimbursement while maintaining VFC compliance.

Code 96110 (developmental screening) is separately reportable, but only if specific conditions are met. The documentation must indicate that a standardized, validated screening tool was administered — such as the Ages and Stages Questionnaire (ASQ), M-CHAT-R/F, PEDS, or BAT — and the results must be documented in the note. Simply writing "developmentally appropriate" or "development on track" without naming the specific tool and documenting the results will result in a denial. Additionally, for commercial payers, 96110 may be bundled into the well-child visit under some NCCI edits, requiring modifier 25. We verify both the documentation and the payer-specific bundling rules before billing to ensure 96110 is paid.

Tympanostomy tube placement (69436) and tonsillectomy/adenoidectomy (42821, 42826) carry 10-day and 90-day global periods respectively. When a pediatrician or ENT surgeon performs these procedures, we track the global period dates for each patient. If a parent brings the child back to your pediatric practice for a post-op check within the global window, we determine whether the visit is included in the surgical global package or qualifies for separate billing (e.g., modifier 24 for an unrelated condition). We also ensure the initial surgical claim is coded correctly — including laterality for tubes (bilateral vs. unilateral) and the correct tonsillectomy code based on the surgical technique.

Medicaid pediatric billing operates under a different set of rules. The EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) program requires more comprehensive screening elements than a standard commercial well-child visit — and your documentation must reflect all EPSDT-required components. Medicaid also reimburses vaccines differently — often with separate administration fee schedules and VFC product rules. Additionally, Medicaid E/M levels may be audited against different criteria than commercial payers, and prior authorization requirements for specialist referrals can be more stringent. We have dedicated Medicaid billing specialists who understand EPSDT documentation requirements, state-specific fee schedules, and the unique appeal processes for Medicaid denials.

We use a transparent percentage-of-collections model — typically 5-8% depending on practice volume, payer mix (Medicaid percentage), and whether you bill for procedures. Pediatric practices benefit enormously from this model because the revenue improvement comes from multiple sources: recovering denied sick visits, correcting vaccine coding to capture product costs, and maximizing Medicaid reimbursement through proper EPSDT documentation. Even recovering 5 previously denied sick/well combination visits per week can offset our entire fee. There are no setup fees, no per-claim charges, and no long-term contracts. If we don't collect, you don't pay.