Pediatrics billing
Pediatrics billing services
We handle billing for pediatric practices, from well-child visits and vaccines to developmental screenings, sick visits and Medicaid claims. Claims go out within 24 hours of receiving charges, every denial is worked within 5 business days, and pricing starts at 2.5% of collections.
- Vaccine counseling codes (90460/90461) and VFC billing
- Well-child visits with same-day sick care (modifier 25)
- Medicaid, CHIP and commercial claims
Why pediatrics billing is different
Vaccines, screenings and well visits drive pediatric revenue
A single well-child visit can carry a preventive code, several vaccines, their administration codes and two or three screenings. Each line has its own rules, and many patients are on Medicaid.
Vaccine administration codes
For patients under 19, when the physician or qualified provider counsels the family, you bill 90460 for each vaccine and 90461 for each extra component. Without that counseling, you use 90471–90474. Picking the wrong set loses money on every shot.
Vaccines for Children (VFC)
VFC vaccines are free to the practice, so you bill only the administration. State Medicaid programs differ on how the product line is reported, such as a zero charge or a specific modifier.
Well visit plus sick visit
When a child comes for a check-up and also needs care for an ear infection or asthma flare, you can bill both with modifier 25 on the problem visit, if the note supports the extra work.
Screenings billed separately
Developmental, behavioral, vision and hearing screenings have their own codes and are billed in addition to the preventive visit. Many payers expect them at set ages.
Newborn care
Newborn visits in the hospital and the first office visits use their own codes, and the baby may not have an insurance ID yet. Claims often wait on the new member number.
Medicaid and CHIP
Many pediatric patients have Medicaid, CHIP or a managed Medicaid plan, with state rules for well-child (EPSDT) services and frequent changes in which plan a child is on.
Common codes
Pediatric codes we bill often
| Code(s) | What it is | What we watch for |
|---|---|---|
| 99381–99385 / 99391–99395 | Preventive visits by age, new and established (infant to age 17) | Age band matches date of birth; modifier 25 on a same-day sick visit |
| 90460 / 90461 | Vaccine administration with counseling, under age 19 | Counseling documented by the physician or qualified provider; one 90461 per extra component |
| 90471–90474 | Vaccine administration without counseling | Used when counseling rules are not met, or for patients 19 and older |
| 96110 / 96127 | Developmental screening; brief behavioral or emotional assessment | Standardized tool named in the note; units per instrument |
| 96161 | Caregiver-focused health risk assessment (such as a parent depression screen) | Billed under the child; payer acceptance varies |
| 99173 / 92551 | Vision screening; hearing screening | Payer rules on ages and how often |
| 99460–99463 | Normal newborn care, initial and later days | Right code for the setting, later days and same-day admit and discharge |
| 99050 / 99051 | Care outside regular office hours | Many payers, including some Medicaid plans, do not pay these |
Codes and rules change. We check current CPT guidance and each payer’s policy before submission.
Common denials we prevent
Pediatric denials we stop before they happen
Pediatric denials often come from vaccine lines, age rules and eligibility. We catch them at charge entry, before they reach the payer.
- Vaccine administration codes that do not match the product codes or counseling
- VFC doses billed with a charge for the vaccine itself
- Preventive visit code that does not fit the child’s age
- Missing or unsupported modifier 25 on a same-day sick visit
- Screenings denied for a missing tool name or outside the payer’s age schedule
- Claims sent to the wrong Medicaid managed care plan after a plan change
- Newborn claims filed before the baby’s own member ID was issued
What we handle
Everything between the visit and the payment
- Insurance eligibility and benefits checks, including Medicaid plan changes
- Charge entry and coding review of preventive visits, vaccines and screenings
- Claim submission within 24 hours of receiving charges
- Payment posting and ERA reconciliation
- Denial correction, resubmission and appeals within 5 business days
- A/R follow-up on unpaid and underpaid claims
- Commercial, Medicaid and CHIP credentialing for pediatricians, NPs and PAs
- Patient statements and balance tracking
- Monthly reporting on collections, denials and A/R
Our billing team does not call families. Patient calls stay with your practice, or with an optional RevenueCTRL virtual assistant.
Pricing
Clear pricing for pediatric practices
Billing starts at 2.5% of collections, or a flat monthly fee. There is no setup fee and no long-term contract. Credentialing starts at $80 per payer, and 5 commercial payers are credentialed free when you sign up for billing.
Our core focus is behavioral health. We bill pediatrics and other specialties with the same team, the same CPB-certified billers and the same service promises. The team also supports Spanish-speaking practices.
Common questions
When do we bill 90460 instead of 90471?
Bill 90460 and 90461 when the patient is under 19 and the physician or other qualified provider counsels the family about each vaccine, and that counseling is documented. Otherwise, bill 90471–90474. Rules vary by payer; we check current policy.
How do you bill Vaccines for Children doses?
You bill only the administration for VFC vaccines, because the vaccine was free. We follow your state Medicaid program’s rules for how the product line is reported, since states handle it differently.
Can we bill a well-child visit and a sick visit together?
Yes, when the child needs care for a problem that takes significant extra work beyond the check-up. We bill the preventive visit and a problem-oriented E/M with modifier 25, and check that the note supports both.
Do you bill developmental and behavioral screenings?
Yes. We bill screenings such as 96110 and 96127 on top of the preventive visit when a standardized tool is used and named in the note, and we follow each payer’s age schedule.
Do you work with Medicaid managed care plans?
Yes. We check eligibility before each visit because children often move between Medicaid plans, and we send the claim to the plan that covered the child on the date of service.
How much does pediatric billing cost?
Billing starts at 2.5% of collections, or a flat monthly fee. There is no setup fee and no long-term contract. We give you an exact quote after a free review of your claims.
Guides from our team
Learn more before you decide
Top 10 Reasons for Medical Claim Denials (And How to Fix Them Fast)
The 10 most common reasons for medical claim denials, what each one costs your practice, and the exact fix for each. Plus a denial-prevention checklist.
Read the guide →Claim Denial Codes Explained: What CO-16, CO-50, CO-197, PR-1 and Others Mean and How to Fix Them
What common denial codes mean (CO-16, CO-18, CO-50, CO-97, CO-197, PR-1 and more) and how to fix each, for mental health and medical practices.
Read the guide →Medical Billing Services for Small Practices: Complete Guide to Maximizing Revenue
Explore medical billing services for small practices, from claim submission and payment posting to denial follow-up, with practical steps to improve revenue.
Read the guide →Find out what your claims are leaving on the table
Tell us about your practice. We will review 90 days of claims and show you what is recoverable, at no cost.
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