Growth-Specific Pediatric Medical Billing Services in the USA

If the provider addresses a significant, separately identifiable problem (such as acute otitis media or asthma) during a well-child visit, both services can be billed. We report the preventive code (99381–99385 for new patients, 99391–99395 for established) along with the problem-oriented E/M code (99202–99205 or 99212–99215) with Modifier 25. Payment still depends on clear documentation and payer policy, so we review notes before submission to reduce bundling denials.

Preventive visit codes depend on the patient's age on the date of service and on whether the patient is new or established:

Vaccine billing has two parts: the vaccine product code (CPT 90476–90759, plus separate COVID-19 vaccine product codes) and an administration code.

• With counseling (through age 18): CPT 90460 for the first or only component of each vaccine and 90461 for each additional component, when a physician or other qualified health care professional counsels the family. COVID-19 vaccine administration is reported with 90480.
• Without counseling (or age 19 and older): CPT 90471–90474, selected by route and reported per vaccine.
• Counseling without vaccination (new in 2026): CPT 90482–90484 are time-based codes for immunization counseling when a recommended vaccine is not given that day. Payer coverage varies, so we check each plan's policy.
• VFC program: The state supplies the vaccine free of charge, so the practice bills only an administration fee. Many Medicaid programs still require the product code to be reported at $0.00 with modifier SL. The exact code set, the line that carries the modifier, and the administration code differ by state, so we follow each state's VFC billing instructions.
• Commercial plans: The practice is paid for both the vaccine product and the administration, based on the payer's fee schedule.

EPSDT is a mandatory Medicaid benefit for children under 21. We follow each state's periodic screening schedule and link screening services with the right diagnosis codes (for example Z00.121 with abnormal findings or Z00.129 without). We also apply state-specific modifiers such as EP where required, and track developmental, hearing, and vision screenings to meet audit standards.

Yes, when standardized instruments are used and documented:

• CPT 96110: developmental screening with scoring and documentation (for example ASQ or M-CHAT).
• CPT 96127: brief emotional or behavioral assessment with scoring and documentation (for example Vanderbilt or PHQ-9/PHQ-A).

We bill the correct units per instrument and follow payer rules on modifiers when these are billed with a preventive visit.

• Normal newborn care: 99460 (initial), 99461 (initial, outside hospital or birthing room), 99462 (subsequent day), 99463 (initial and discharge on the same day).
• Delivery services: 99464 (attendance at delivery) and 99465 (delivery room resuscitation).
• Intensive and critical care: 99477 (initial neonatal intensive care), 99468–99469 (neonatal critical care, 28 days or younger), and 99478–99480 (subsequent intensive care, selected by the infant's present weight). These are reported per day.

• Common causes are:

  • Wrong preventive code for the child's age.
  • Missing Modifier 25 on same-day well and sick visits.
  • Incorrect vaccine component counts or missing VFC modifiers.
  • Unverified Medicaid/CHIP eligibility or wrong primary/secondary order.
  • Missed timely filing limits.

  We reduce these with pre-submission claim scrubbing, eligibility checks before appointments, and follow-up on denied claims.

Medicaid and CHIP follow state-specific rules on covered services, prior authorization, and timely filing. Our team keeps rule sets updated for each state program and managed care organization (MCO), so EPSDT visits, vaccine administration, and referrals are billed correctly.

Yes, we work with major pediatric-focused and general EHR/practice management systems, including Office Practicum (OP), PCC, eClinicalWorks, Epic, and Tebra (formerly Kareo). Integration lets us receive charges, encounter notes, and immunization records directly, which reduces manual entry and speeds up clean claim submission. Feel free to ask us about your specific system.

A child is a new patient if they have not received professional services from the same physician, or another physician of the same specialty in the same group, within the past three years. This decides whether you bill 99381–99385 or 99391–99395, and 99202–99205 or 99212–99215.

Yes, when they are performed and documented. Common codes are 99173 (visual acuity screening), 99177 (instrument-based ocular screening with on-site analysis), 99174 (instrument-based screening with remote analysis), 92551 (pure tone hearing screening), and 92558 (otoacoustic emissions screening). Some payers require modifier 25 on the E/M or modifier 59 on the screening, and some bundle these services, so we check each payer's policy before billing.

Telehealth billing depends on the payer and the state. Claims commonly need the correct place of service (02 or 10) and a telehealth modifier (95 for audio-video visits, 93 for audio-only where covered). We check current payer and state Medicaid telehealth policies before submitting claims.

Coordination of benefits decides which plan pays first. For married parents, the "birthday rule" applies: the plan of the parent whose birthday falls earlier in the calendar year is primary. For divorced or separated parents, a court order comes first, then the custodial parent's plan. Medicaid is generally the payer of last resort. We verify this order before submission to avoid denials.

 Yes. We track every denial, find the root cause, correct and resubmit claims, and file appeals with supporting documentation within payer deadlines. We also share denial trends with your practice so the same errors do not repeat.

Pricing depends on your practice size, claim volume, and payer mix. Most billing companies charge either a percentage of monthly collections or a flat fee per claim. We give you a clear written quote with all fees listed before you start.