Pediatric Billing Cheat Sheet (2026)
Pediatric billing leaks in three predictable places: the same-day well and sick visit billed as one, vaccine administration handled wrong under the Vaccines for Children program, and developmental screening never captured.
Quick reference for pediatric billers. Last updated .
Top Pediatric CPT Codes & 2026 Medicare Allowables
| Code | Description | Non-Facility | Facility | Total RVU |
|---|---|---|---|---|
| 99391 | Preventive medicine visit, established, under age 1 | $102.54 | $58.45 | 3.07 |
| 99392 | Preventive medicine visit, established, age 1-4 | $108.89 | $63.80 | 3.26 |
| 99393 | Preventive medicine visit, established, age 5-11 | $108.55 | $63.80 | 3.25 |
| 99394 | Preventive medicine visit, established, age 12-17 | $119.24 | $72.81 | 3.57 |
| 99381 | Preventive medicine visit, new patient, under age 1 | $113.56 | $63.80 | 3.40 |
| 99383 | Preventive medicine visit, new patient, age 5-11 | $123.92 | $72.81 | 3.71 |
| 90460 | Immunization administration, single vaccine, age 0-18 | $23.38 | $23.38 | 0.70 |
| 90461 | Immunization administration, each additional vaccine | $8.68 | $8.68 | 0.26 |
| 99213 | Established patient office visit, low MDM | $95.19 | $57.45 | 2.85 |
| 99214 | Established patient office visit, moderate MDM | $135.61 | $84.50 | 4.06 |
National 2026 Medicare Physician Fee Schedule estimates (total RVU multiplied by the conversion factor). These are adjusted by state locality. See the per-state table on the Pediatric billing services page.
Modifiers That Prevent Pediatric Denials
A significant, separately identifiable sick E/M on the same day as a well-child visit. This is the core pediatric modifier.
A distinct service unbundled from another that NCCI would otherwise combine.
A preventive service with the cost share waived, distinguishing it from a diagnostic version of the same service.
A service delivered under the Medicaid EPSDT well-child program where the state requires the EP designator.
A state-supplied vaccine under the Vaccines for Children program, so only the administration is billed, not the product.
A synchronous telehealth visit where the payer and state allow it for pediatrics.
Top Pediatric Denials → Quick Fix
Bill the age-appropriate preventive code plus the sick E/M with modifier 25, documenting the problem evaluation separately from the well-child exam.
State-supplied Vaccines for Children product is not separately payable. Bill only the administration (90460, 90461) with the SL modifier where required; do not bill the product.
90460 is per component with provider counseling for patients through age 18; 90461 each additional component. Document the counseling and components, or use 90471 and 90472 when counseling criteria are not met.
Match the code to the patient age band (99381 to 99394). A mismatched age code is a coding-accuracy denial.
96110 developmental screening is separately billable with a standardized instrument. Document the tool and result; it is frequently performed and never billed.
NCCI Bundling Watch-Outs
Code pairs from this specialty's set that carry NCCI edits. Billing both without a justified modifier triggers a bundling denial.
| Code | Bundles With | Rationale |
|---|---|---|
| 99391 | 0362T | Misuse of Column Two code with Column One code |
| 99391 | 0373T | Misuse of Column Two code with Column One code |
| 99392 | 0362T | Misuse of Column Two code with Column One code |
| 99392 | 0373T | Misuse of Column Two code with Column One code |
| 99393 | 0362T | Misuse of Column Two code with Column One code |
| 99393 | 0373T | Misuse of Column Two code with Column One code |
| 99394 | 0362T | Misuse of Column Two code with Column One code |
| 99394 | 0373T | Misuse of Column Two code with Column One code |
Documentation That Holds Up on Appeal
The age-appropriate comprehensive history and exam and the age band.
A separate problem-oriented note distinct from the well-child documentation, supporting modifier 25.
Each component and the provider counseling for patients through 18, or the 90471 series basis when counseling criteria are not met.
That the dose was state-supplied, so only the administration is billed, with the SL modifier where required.
The standardized instrument used and the result.
Revenue Pediatric Practices Leave on the Table
Not billing the same-day sick visit with modifier 25 alongside the well-child exam, the largest pediatric leak.
Billing the VFC product to the payer, which denies, instead of billing only the administration.
Using 90471 when 90460 with counseling was supported and pays more for the age group.
Performing developmental and autism screening and never billing 96110.
Pediatric Billing FAQ
Can I bill a sick and well visit on the same day?
Yes. Bill the age-appropriate preventive code plus the problem E/M with modifier 25, with the sick evaluation documented separately from the well-child exam. This is the most commonly missed pediatric revenue.
How do I bill VFC vaccines?
For state-supplied Vaccines for Children doses, bill only the administration (90460, 90461) with the SL modifier where the state requires it. Billing the product to the payer denies because the state supplied it.
When is 90460 used instead of 90471?
90460 is per vaccine component with provider counseling for patients through age 18; 90461 is each additional component. Use 90471 and 90472 when the counseling criteria are not met. The counseling and components have to be documented.
Is developmental screening separately billable?
Yes. 96110 is separately billable when a standardized instrument is used and the tool and result are documented. It is frequently performed and rarely captured.
Stop Losing Pediatric Revenue to Preventable Denials
Our AAPC-certified pediatric coders apply every rule on this sheet to your claims. Call 888-701-6090 for a free billing assessment.