Specialty billing
Pediatrics Medical Billing Services
Pediatric billing is high-volume and low-margin, built on well-child visits, immunization administration and developmental screening. Immunization administration codes are among the most frequently underbilled services in medicine, because administration is billable separately from the vaccine product itself and is routinely omitted.
Pediatrics benchmarks
- Typical denial rate
- 8–13%
- Days in AR
- 28–40
- Achievable clean claim rate
- 97%+
Typical ranges for pediatric practices. Your actual numbers are measured during the audit.
The complexity
Why pediatrics is uniquely difficult to bill
Immunization administration bills separately from the vaccine product and is frequently omitted
Administration codes differ by whether counseling was provided and by patient age
Well-child visit codes are selected by patient age and new-versus-established status
Developmental and behavioral screening tools each carry their own billable code
Vaccines for Children program stock cannot be billed as product, only as administration
Sick visits on the same day as well visits require modifier 25 and separate documentation
Coding
Pediatrics procedure codes we work with daily
A representative sample, not an exhaustive list. Coders are assigned by specialty rather than pooled.
| Code | Description |
|---|---|
| 99392 | Preventive medicine visit, established patient, ages 1–4 |
| 99393 | Preventive medicine visit, established patient, ages 5–11 |
| 90460 | Immunization administration with counseling, first component |
| 90461 | Immunization administration with counseling, each additional component |
| 96110 | Developmental screening with scoring and documented report |
| 96127 | Brief emotional or behavioral assessment with scoring and report |
Revenue leakage
Where pediatrics practices lose money
These are the denial patterns specific to this specialty — the ones a general-purpose billing service will not be looking for.
Administration codes omitted
Vaccine products billed without the corresponding administration codes, forfeiting the administration fee entirely.
Component counting errors
Combination vaccines billed as a single component when each antigen counts separately under 90460 and 90461.
VFC product billing
State-supplied Vaccines for Children stock billed as product, which is never payable — only administration is.
Same-day visit conflicts
Sick visit billed alongside a well visit without modifier 25 or without documentation supporting a separately identifiable service.
Screening documentation
Screening codes denied where the note does not include the standardized instrument used and its scored result.
Payer landscape
What pediatric practices need to know about payers
Payer policy drives more pediatrics denials than coding does. Knowing the policy before the service is what prevents them.
- Medicaid and CHIP make up a large share of pediatric volume, with state-specific EPSDT periodicity schedules governing covered well-visit frequency.
- Vaccines for Children program stock is state-supplied — bill administration only, never the product.
- Some commercial payers bundle developmental screening into the preventive visit; others reimburse it separately. This must be tracked per payer.
Questions
Pediatrics billing FAQ
Last updated August 20, 2026
Reviewed by a certified coding leadBecause administration is a separate billable service from the vaccine product, and combination vaccines count each antigen as its own component. A single combination vaccine can support one 90460 plus multiple 90461 units. Practices that bill one administration code per injection rather than per component leave money on the table at nearly every well visit.
Administration only. The vaccine product itself is state-supplied at no cost and is never billable — submitting it produces a denial and, if systematic, an audit flag. The administration fee remains fully billable and is the entire revenue from a VFC encounter.
Yes, when the sick complaint is genuinely separate from the preventive service. The problem-focused visit is billed with modifier 25, and the documentation must clearly support two distinct services. Payers scrutinize this pairing, so the note needs to stand on its own for each.
Using 96110 for developmental screening and 96127 for brief emotional or behavioral assessment, each requiring a standardized instrument with a documented, scored result. A note saying development was discussed does not support the code; the instrument name and score do.
Primary sources
Coverage, rates and local policy for pediatrics, at the source.
- State Medicaid program overviews (opens in a new tab)
Medicaid.gov — Program structure, delivery model and waivers by state. Our state pages summarise the program name and delivery model; this is the authoritative source behind them.
- Medicare Coverage Database (LCD/NCD) (opens in a new tab)
Centers for Medicare & Medicaid Services — Searchable national and local coverage determinations. The direct answer to whether a diagnosis supports medical necessity for a given procedure.
- CPT code set (opens in a new tab)
American Medical Association — Maintainer of CPT. Annual changes to CPT are the most common cause of a sudden, unexplained rise in denials each January.
Services pediatric practices use most
Get a free pediatrics billing audit
We'll review your pediatrics denial patterns, coding accuracy and AR aging against the benchmarks above. Takes about two minutes to request.
No setup fees · You pay when we collect · Pricing from 3% of net collections