Pediatric Billing Services

Pediatric practices run on well-child visits, vaccines and screenings. Most of that work is billed to Medicaid, the Children's Health Insurance Program and commercial plans, and each has its own schedule of covered services. A visit can include a preventive exam, several vaccines and a sick concern, all on one claim.

Pediatric billing also has to follow the child, not the visit. Coverage changes when parents change jobs, and two parents may each have a plan. Westmont Revenue Partners connects pediatric practices with vetted billing experts who understand vaccine coding, screening instruments and coordination of benefits, so claims are accurate and payments are tracked closely.

Who this is for

• Pediatricians in solo, group and multi-site practices
• Nurse practitioners and physician assistants in pediatric clinics
• Practices with a high share of Medicaid and CHIP patients
• Clinics that run in-house vaccine programs
• Newborn nurseries and hospital-based pediatric groups

What gets billed

• Newborn hospital care
• Well-child visits from infancy through young adulthood
• Sick visits for infections, asthma and injuries
• Vaccine products and vaccine administration
• Developmental screening
• Autism screening
• Emotional and behavioral screening tools
• Vision and hearing screening
• Point-of-care tests such as rapid strep
• Counseling at the time of vaccine administration
• Sports and school physicals

Commonly billed codes

Code	Type	What it covers
99391	CPT	Preventive visit, established patient, under 1 year
99392	CPT	Preventive visit, established patient, ages 1 to 4
99393	CPT	Preventive visit, established patient, ages 5 to 11
99394	CPT	Preventive visit, established patient, ages 12 to 17
99460	CPT	Exam and care of a healthy newborn in the hospital
96110	CPT	Developmental screening with a scored tool
96127	CPT	Brief emotional or behavioral screening with a scored tool
90460	CPT	Vaccine administration with counseling, first component, patient 18 or younger
90461	CPT	Each added vaccine component given with counseling
87880	CPT	Rapid test for group A strep
99213	CPT	Established patient sick visit, low level
Z00.129	ICD-10-CM	Routine child health exam, no abnormal findings
Z00.121	ICD-10-CM	Routine child health exam, with abnormal findings

Note

Codes are examples for orientation, not a complete list, and do not guarantee coverage or payment. Always check current code sets and payer policy.

Billing challenges in pediatrics

Vaccine component counting. Vaccine administration codes depend on the number of components and whether counseling was given. Billers match each shot to the right code and product so claims reflect what was given.

Sick visit during a well visit. A child may have an ear infection at a checkup. Billers know when a separate visit with modifier 25 is supported and which payers want proof of a distinct problem.

Screening limits. Developmental, autism and behavioral screens have frequency limits that vary by payer and state. Billers track age-based limits so screens are not billed too often.

Two-parent and custody coverage. A child may have coverage under both parents. Billers verify which plan is primary using the birthday rule or court orders, then bill the right payer first.

Medicaid and CHIP differences. Each state sets its own rules, forms and code lists. Billers keep a state-by-state reference and update it when programs change.

Newborn enrollment delays. Babies are often not yet in the payer system at birth. Billers hold or re-bill claims once enrollment posts, and document the time limits.

Vaccine stock and cost recovery. Practices buy vaccines up front and wait to be paid. Billers watch for underpayments against what was paid for the product.

How Westmont can help

• Matching you with vetted billing experts who have worked with pediatric practices
• End-to-end revenue cycle support, including vaccine and screening claims
• Denial management for well-visit and screening denials
• Credentialing support for new providers and Medicaid enrollment
• Clear reports on aging claims and payer trends

Frequently asked questions

What does pediatric medical billing involve?

Pediatric medical billing covers well-child visits, sick visits, newborn care, vaccines and screening tools. It also covers coordinating coverage between parents, Medicaid and commercial plans. A good pediatric billing company knows age-based preventive codes, vaccine coding and each payer's screening limits. Westmont connects you with vetted experts who handle these tasks.

Can I bill a sick visit on the same day as a well-child visit?

Often yes, if the sick concern needs separate work beyond the routine exam and is documented on its own. Many payers expect modifier 25 on the sick visit. Some limit when they pay both, so your biller should confirm each payer's policy.

How are vaccines billed in a pediatric office?

Each vaccine has a product code, and the shot itself has an administration code. When the provider counsels the family at the visit for patients 18 and younger, counseling-based administration codes may apply. Payers differ in what they require, so your biller should check each policy.

How often can I bill developmental screening?

Frequency depends on the payer. Many follow guidance from pediatric societies and state Medicaid programs and allow screening at set ages. Check current payer and state policies, and make sure the tool used and the score are documented. Keeping a screening log by patient age helps front desk staff and billers avoid duplicate or missed screens.

Why are newborn claims delayed?

Newborns often are not yet enrolled with the parent's payer when the claim is ready. Payers also have time limits for adding a baby to a plan. Billers track these dates, resubmit when coverage posts, and keep records that show the claim was filed on time.

Related billing services

• Adolescent Medicine
• Family Medicine
• Preventive Medicine
• Urgent Care
• Neonatology / NICU
• Child & Adolescent Psychiatry