Specialty billing
Pediatrics Billing Services
Pediatric billing combines age-based preventive codes, frequent vaccinations, developmental screenings and a payer mix that often includes Medicaid and CHIP.
Rules to watch
- Newborn coverage and eligibility timing
- Medicaid and CHIP program rules
- Vaccine administration vs. counseling codes
- Screening frequency and modifiers
- Sick visits during well-child visits (modifier 25)
What makes pediatric billing different?
Pediatric billing runs on age-based codes and a lot of vaccines. Well-child visits are coded by the child’s age and whether they are new or established, and almost every visit carries vaccine administration, screening or counseling codes on top. Many patients are covered by Medicaid or CHIP, which bring their own enrollment, eligibility and frequency rules. For vaccines supplied through the Vaccines for Children program, the practice bills only for giving the shot, not for the vaccine itself. The common problems are small but constant: the wrong administration code for the patient’s age, counseling codes billed without documented counseling, and newborns seen before their coverage is active.
What makes it different
What makes pediatrics billing different
Codes at a glance
Common pediatrics codes and what to watch
| Service | Codes | What to watch |
|---|---|---|
| Preventive visit, new | 99381 (under 1), 99382 (1–4), 99383 (5–11), 99384 (12–17) | Code by age on the date of service |
| Preventive visit, established | 99391–99394 (same age bands) | A separate sick visit needs modifier 25 |
| Vaccine admin with counseling | 90460, +90461 | Through age 18; counseling documented per component |
| Vaccine admin without counseling | 90471, +90472 | Used when counseling criteria are not met |
| Developmental screening | 96110 | Reported separately from the visit |
Related services
Services that matter most for pediatrics
FAQ
Pediatrics billing questions
How are vaccines billed for VFC patients?
Vaccines supplied through the Vaccines for Children program are not billed as products. The practice bills the administration, following the state Medicaid program’s rules.
When are 90460 and 90461 used instead of 90471?
Codes 90460 and 90461 are used when a physician or other qualified professional provides face-to-face counseling about the vaccine for a patient through 18 years of age. Otherwise, standard administration codes such as 90471 apply.
Coding rules change every year. The code references on this page reflect general guidance at the time of writing. Payer policies and your documentation always determine what is billable.
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