Pediatric Billing Services

Pediatric billing has its own coding universe — well-child visit codes separate from sick visits, Vaccines for Children (VFC) program rules, developmental screening codes, immunization administration with component-count billing, and EPSDT requirements for Medicaid-enrolled children.

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99392Well-Child 1-4yr

96110Dev Screening

90460Immunization Admin

99460Newborn Care

Why Pediatric Billing Requires Specialty Expertise

Pediatric billing requires mastering age-specific well-child visit codes (99381-99395 for new patients, 99391-99395 for established), immunization administration codes that differ by patient age and number of vaccine components, developmental screening (96110), and Medicaid EPSDT requirements that guarantee comprehensive coverage for children under 21. Newborn care codes 99460-99463 cover initial and subsequent hospital care.

Common Pediatric CPT Codes

Our coders handle these pediatric codes daily. This is not an exhaustive list.

Code

Description

99391

Preventive medicine visit, established, under age 1

99392

Preventive medicine visit, established, age 1-4

99393

Preventive medicine visit, established, age 5-11

99394

Preventive medicine visit, established, age 12-17

99381

Preventive medicine visit, new patient, under age 1

99383

Preventive medicine visit, new patient, age 5-11

90460

Immunization administration, single vaccine, age 0-18

90461

Immunization administration, each additional vaccine

99213

Established patient office visit, low MDM

99214

Established patient office visit, moderate MDM

2026 Medicare Allowables for Pediatric CPT Codes by State

Medicare reimbursement for pediatricprocedures is not a single national number. Each code's allowable is adjusted by your state's Geographic Practice Cost Index (GPCI) and processed under that state's Medicare Administrative Contractor (MAC), so the same pediatric CPT code pays a different amount in California than it does in Texas or Florida. The table below shows the 10 core pediatriccodes our coders bill priced at each state's 2026 locality. The non-facility figure is what an office-based practice collects. The facility figure applies when the service is performed in a hospital-based setting.

Commercial carriers in each state typically reimburse above these Medicare benchmarks and state Medicaid below them, but the Medicare allowable is the contracting anchor every payer negotiation starts from. Compare any individual code across all states with our Medicare fee calculator by state.

2026 Medicare non-facility allowable for Pediatric CPT codes across high-volume states
Code	Pediatric Procedure	CA	TX	FL	NY	PA	IL	OH	GA	NC	MI
99391	Preventive medicine visit, established, under age 1	$112.87	$101.76	$105.25	$111.93	$102.03	$103.31	$97.85	$100.64	$97.95	$100.33
99392	Preventive medicine visit, established, age 1-4	$119.74	$108.10	$111.60	$118.71	$108.38	$109.61	$104.03	$106.91	$104.16	$106.56
99393	Preventive medicine visit, established, age 5-11	$119.35	$107.77	$111.27	$118.34	$108.05	$109.28	$103.72	$106.59	$103.85	$106.24
99394	Preventive medicine visit, established, age 12-17	$130.37	$118.38	$122.91	$130.05	$118.80	$120.80	$114.16	$117.34	$113.98	$117.15
99381	Preventive medicine visit, new patient, under age 1	$125.28	$112.70	$116.29	$123.92	$112.95	$114.12	$108.30	$111.37	$108.53	$110.94
99383	Preventive medicine visit, new patient, age 5-11	$135.90	$122.98	$127.61	$135.27	$123.38	$125.32	$118.43	$121.81	$118.34	$121.55
90460	Immunization administration, single vaccine, age 0-18	$26.10	$23.14	$24.07	$25.72	$23.19	$23.51	$22.08	$22.84	$22.13	$22.73
90461	Immunization administration, each additional vaccine	$9.18	$8.66	$9.01	$9.36	$8.71	$8.93	$8.48	$8.66	$8.41	$8.68
99213	Established patient office visit, low MDM	$104.31	$94.46	$98.20	$103.97	$94.79	$96.44	$90.97	$93.60	$90.84	$93.44
99214	Established patient office visit, moderate MDM	$148.01	$134.59	$140.26	$148.05	$135.13	$137.84	$129.83	$133.55	$129.44	$133.44

Full Pediatric fee detail by state

State:

2026 Medicare allowables for pediatric CPT codes in California, processed under Noridian Healthcare Solutions (Jurisdiction E). See California medical billing.

2026 Medicare allowables for Pediatric CPT codes in California
Code	Description	Non-Facility	Facility
99391	Preventive medicine visit, established, under age 1	$112.87	$60.70
99392	Preventive medicine visit, established, age 1-4	$119.74	$66.39
99393	Preventive medicine visit, established, age 5-11	$119.35	$66.39
99394	Preventive medicine visit, established, age 12-17	$130.37	$75.43
99381	Preventive medicine visit, new patient, under age 1	$125.28	$66.39
99383	Preventive medicine visit, new patient, age 5-11	$135.90	$75.43
90460	Immunization administration, single vaccine, age 0-18	$26.10	$26.10
90461	Immunization administration, each additional vaccine	$9.18	$9.18
99213	Established patient office visit, low MDM	$104.31	$59.65
99214	Established patient office visit, moderate MDM	$148.01	$87.54

Source: 2026 Medicare Physician Fee Schedule, locality-adjusted by state MAC. Figures are for reference and contracting benchmarks, not a guarantee of payment.

Pediatric Billing Challenges We Solve

Common billing problems in pediatric and how our team handles them.

Well-Child vs Sick Visit Billing

When a well-child visit includes a significant separate problem, both the preventive code and a problem-oriented E/M code can be billed with modifier 25 — but documentation must support both.

VFC Program Compliance

Vaccines for Children provides free vaccines for Medicaid-eligible children, but practices can only bill the administration fee, not the vaccine cost. Mixing VFC and private stock causes compliance violations.

Immunization Administration Coding

Code selection depends on patient age (90460 for under 18, 90471 for 18+), first vs additional vaccine, and number of antigen components per vaccine.

EPSDT Coverage Requirements

Medicaid EPSDT requires coverage of all medically necessary services for children under 21, even services not in the state Medicaid plan. This creates appeal opportunities for denied services.

Common Pediatric Denial Reasons

We prevent these before submission and appeal aggressively when they occur.

When a well-child visit includes a significant separate problem, both the preventive code and a problem-oriented E/M code can be billed with modifier 25 — but documentation must support both

Vaccines for Children provides free vaccines for Medicaid-eligible children, but practices can only bill the administration fee, not the vaccine cost

Code selection depends on patient age (90460 for under 18, 90471 for 18+), first vs additional vaccine, and number of antigen components per vaccine

Medicaid EPSDT requires coverage of all medically necessary services for children under 21, even services not in the state Medicaid plan

Revenue Opportunities Most Pediatric Practices Miss

Modifier 25 optimization is the largest revenue opportunity in pediatric billing. Studies show 30-40% of well-child visits include a significant separate problem (ear infection, eczema flare, behavioral concern) that qualifies for a separate E/M code. For a pediatric practice seeing 40 well-child patients per day, billing the additional E/M code on 30% of visits at $50-75 per code adds $150,000 to $225,000 annually. Developmental screening (96110) is the second most commonly missed pediatric billing opportunity. The AAP recommends developmental screening at 9, 18, and 30 months and autism-specific screening at 18 and 24 months. At $15-20 per screening, a practice seeing 200 well-child visits per month should generate $36,000-48,000 annually from developmental screening alone. Most practices perform screenings but fail to bill the code.

Payer-Specific Pediatric Billing Tips

Medicaid is the dominant payer in pediatrics, covering approximately 40% of all children in the United States. Medicaid reimburses well-child visits, immunizations (administration fee only for VFC-eligible patients), developmental screenings, and EPSDT-mandated services. Reimbursement rates vary significantly by state — Texas Medicaid reimburses 99392 at $80, while New York Medicaid pays $120 for the same code. Commercial payers including UnitedHealthcare, Anthem BCBS, Aetna, and Cigna cover preventive pediatric services at 100% under the ACA with no patient cost-sharing. Immunization vaccine costs are covered separately from administration fees. However, commercial payers frequently deny modifier 25 claims for combined well-child and sick visits, requiring documentation that clearly demonstrates two distinct services. We maintain payer-specific documentation templates that satisfy modifier 25 requirements for each major payer.

Pediatric Billing Best Practices

Practical tips from our coding team to maximize reimbursement and minimize denials.

When a well-child visit includes evaluation and management of a significant separate problem, bill both the preventive code (99391-99395) and the appropriate E/M code (99212-99215) with modifier 25 on the E/M code. Documentation must clearly separate the preventive and problem-oriented portions.

Immunization administration for children under 18 uses 90460 (first vaccine component) and 90461 (each additional component). A combination vaccine like DTaP-IPV-Hep B (Pediarix) has three components, so bill 90460 x1 and 90461 x2. This component-based billing is unique to pediatrics.

Bill developmental screening (96110) at every recommended well-child visit using a standardized tool (ASQ, M-CHAT, PEDS). The code reimburses $15-20 per screening and is separately billable from the preventive visit.

For newborn care, 99460 covers the initial assessment on the date of birth, 99462 covers subsequent daily care, and 99463 covers the initial assessment plus same-day discharge. Circumcision (54150) is separately billable.

Medicaid EPSDT entitles children under 21 to any medically necessary service. When Medicaid denies a service for a child, appeal citing the EPSDT mandate — payers must cover services beyond the standard Medicaid plan if medically necessary.

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What We Handle for Pediatric Practices

Well-child preventive visit coding (99381-99395)

Immunization administration and vaccine billing

VFC program compliance and administration-fee billing

Developmental screening coding (96110)

Newborn hospital care billing (99460-99463)

EPSDT compliance and Medicaid appeals

Modifier 25 optimization for combined well-child/sick visits

Pediatric chronic care management

Why Choose Go Medical Billing for Pediatric

Pediatric billing's age-specific codes, VFC program rules, and EPSDT requirements are unlike any other specialty. Our team handles the nuances of well-child billing, immunization administration, and Medicaid pediatric coverage.

We serve pediatric practices in all 50 states, starting at 2.49% of collections. Our credentialing team handles payer enrollment, and our A/R specialists recover aging claims.

Pediatric Billing by State

We handle pediatric billing in all 50 states. The 2026 Medicare allowables for pediatric CPT codes in every state are in the fee table above. Open any state below for its full payer environment, Medicaid rules, and Medicare MAC policies.

California Texas Florida New York Pennsylvania Illinois Ohio Georgia North Carolina Michigan New Jersey Virginia Massachusetts Arizona Tennessee Maryland Indiana Missouri Wisconsin Colorado

View all 50 states

Related Resources

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Frequently Asked Questions

Yes. For VFC-eligible patients, we bill only the immunization administration fee (90460/90461) and exclude the vaccine product cost. We track VFC eligibility and ensure private stock is billed correctly for non-VFC patients.

When Medicaid denies a medically necessary service for a child under 21, we prepare EPSDT-based appeals citing federal mandate requirements. EPSDT requires Medicaid to cover all medically necessary services regardless of whether they are included in the state plan.

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