Pediatric billing has a fundamentally different structure from adult medicine billing. Age-based preventive medicine codes replace standard E/M codes for well visits, immunization administration has its own coding framework, developmental screening services have specific codes, and Medicaid EPSDT requirements create additional complexity for practices serving a significant Medicaid population.

Getting these codes right matters financially. A practice that consistently confuses well-child visit codes with E/M codes — or misses immunization administration codes — can lose tens of thousands of dollars in legitimate revenue annually.

Well-Child Visit Codes — Preventive Medicine Services

Well-child visits are billed using preventive medicine codes (99381–99395), not standard E/M codes (99202–99215). The code selected depends on whether the patient is new or established to the practice, and the patient's age at the time of the visit.

New Patient Preventive Medicine Visits

• 99381 — Initial preventive medicine, new patient, infant — age younger than 1 year
• 99382 — Initial preventive medicine, new patient, early childhood — age 1 through 4 years
• 99383 — Initial preventive medicine, new patient, late childhood — age 5 through 11 years
• 99384 — Initial preventive medicine, new patient, adolescent — age 12 through 17 years
• 99385 — Initial preventive medicine, new patient, 18–39 years (adult, for reference)

Established Patient Preventive Medicine Visits

• 99391 — Periodic preventive medicine, established patient, infant — younger than 1 year
• 99392 — Periodic preventive medicine, established patient, early childhood — 1 through 4 years
• 99393 — Periodic preventive medicine, established patient, late childhood — 5 through 11 years
• 99394 — Periodic preventive medicine, established patient, adolescent — 12 through 17 years

Immunization Administration CPT Codes

Vaccine administration codes are billed in addition to the vaccine product codes. Both the administration code and the product code must appear on the same claim for complete reimbursement. The administration code selection depends on whether the patient is under 18 years old, whether counseling was provided, and the route of administration.

Immunization Administration With Counseling (For Patients Under 18)

• 90460 — Immunization administration through 18 years of age via any route of administration, with counseling by physician — first or only vaccine/toxoid component
• 90461 — Each additional vaccine/toxoid component (add-on code to 90460, report once per additional antigen)

Immunization Administration Without Counseling (or 19 Years and Older)

• 90471 — Immunization administration, first injection
• 90472 — Immunization administration, each additional injection (add-on to 90471)
• 90473 — Immunization administration, first intranasal or oral vaccine
• 90474 — Immunization administration, each additional intranasal or oral vaccine (add-on to 90473)

Common Pediatric Vaccine Product Codes

• 90700 — DTaP vaccine (diphtheria, tetanus, acellular pertussis) — for patients younger than 7 years
• 90707 — MMR vaccine (measles, mumps, rubella), live
• 90710 — MMRV vaccine (measles, mumps, rubella, varicella), live
• 90713 — Poliovirus vaccine, inactivated (IPV), per dose
• 90716 — Varicella virus vaccine (Varivax), live, per dose
• 90723 — DTaP-HepB-IPV vaccine (Pediarix), for intramuscular use
• 90740 — Hepatitis B vaccine, dialysis or immunosuppressed patient, 40 mcg, 3-dose schedule
• 90744 — Hepatitis B vaccine, pediatric/adolescent, 3-dose schedule, per dose
• 90746 — Hepatitis B vaccine, adult, 3-dose schedule, per dose
• 90748 — Hepatitis B and Hib vaccine (Comvax), intramuscular use

Billing a Sick Visit at the Same Appointment as a Well-Child Visit

This is one of the most common — and most commonly mishandled — situations in pediatric billing. When a parent brings a child in for a scheduled well-child visit but also raises a new problem (an ear infection, a rash, a behavioral concern) that the physician addresses during the same visit, both services can be billed separately.

To bill both, append Modifier 25 to the E/M code. Modifier 25 signals to the payer that a significant, separately identifiable evaluation and management service was performed on the same day as the preventive medicine service. Without Modifier 25, the payer will bundle both charges and pay only the higher-value one.

Developmental and Behavioral Screening Codes

• 96110 — Developmental screening with scoring and documentation, per standardized instrument — e.g., ASQ, M-CHAT for autism screening, PEDS
• 96127 — Brief emotional/behavioral assessment with scoring and documentation, per standardized instrument — e.g., PHQ-A for adolescent depression, SCARED, Vanderbilt for ADHD
• 96160 — Administration of patient-focused health risk assessment instrument — report per standardized instrument with scoring and documentation
• 99408 — Alcohol and/or substance (other than tobacco) abuse structured screening and brief intervention services — 15 to 30 minutes
• 99409 — Alcohol and/or substance abuse structured screening and brief intervention services — greater than 30 minutes

Medicaid EPSDT — What Pediatric Practices Need to Know

The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program requires state Medicaid programs to provide comprehensive preventive health services for individuals under age 21. EPSDT coverage often includes services that commercial insurance does not cover — including hearing screens, vision screens, dental screens, and developmental assessments beyond standard well-child visit components.

Each state's Medicaid program has specific EPSDT billing codes, encounter forms, and documentation requirements. Practices serving a significant Medicaid population should work with a billing team familiar with their specific state's EPSDT billing requirements.

Top Pediatric Billing Errors

• Billing E/M codes (99213, 99214) for well-child visits instead of preventive medicine codes (99391–99394)
• Billing preventive medicine codes for sick visits — preventive codes are only appropriate for scheduled well-child examinations
• Missing modifier 25 on the E/M code when billing a sick visit on the same day as a well-child visit
• Not billing immunization administration codes separately from vaccine product codes
• Using 90460/90461 for patients age 19 and older — use 90471/90472 instead
• Missing 96110 developmental screening charges even when the screening was performed during the visit
• Not billing the correct number of 90461 add-on units for combination vaccines

How HNA Supports Pediatric Practices

Our pediatric billing specialists understand well-child visit coding, immunization administration code selection, modifier 25 requirements, developmental screening codes, and state-specific Medicaid EPSDT rules. HNA pediatric clients consistently capture all preventive services, screening codes, and immunization administration fees that are frequently missed by in-house or generalist billing teams.