Pediatric billing might seem straightforward, but it comes with its own set of unique challenges. From frequent well-child visits to age-specific vaccine schedules and coordination with secondary insurance, pediatric billing requires precision and careful attention to payer rules.
This article outlines the most common mistakes seen in pediatric billing—and how to prevent them to ensure smoother reimbursement and fewer denials.
Vaccinations are a core part of pediatric care and billing. Mistakes often happen when either:
The administration code is left off
The wrong combination of product and administration codes is used
Age-specific vaccine codes are billed incorrectly
How to avoid it:
Always bill both the vaccine product and the administration code. Match codes to the child’s age and follow payer guidelines for reporting combination vaccines. Confirm NDC numbers when required by the payer.
Routine well-child visits should be billed using CPT codes based on the patient’s age, not just the visit type. Common errors include using outdated codes or failing to include necessary components (like screenings).
How to avoid it:
Use age-appropriate CPT codes (e.g., 99381–99385 for new patients, 99391–99395 for established). Confirm documentation includes all required elements—such as anticipatory guidance, developmental screening, and growth charting.
These screenings are often separately billable but frequently go unbilled because they’re considered part of the well visit—or missed entirely.
How to avoid it:
Use CPT codes like 96110 (developmental testing, limited) or 96127 (brief emotional/behavioral assessment) when screenings are performed and documented. Confirm payer coverage and attach the correct diagnosis code (e.g., Z13.4 for developmental screening).
Pediatric patients are often covered by more than one policy (e.g., both parents). If COB isn’t managed correctly, claims can be delayed or denied.
How to avoid it:
Verify primary vs. secondary coverage before submitting claims. Use clearinghouse tools or payer portals to confirm COB status regularly, especially for new patients or updated insurance plans.
Pediatricians often perform multiple services during a single visit—like a sick visit during a well-child exam. Without the correct modifier, one of those services may be denied as bundled.
How to avoid it:
Use modifier 25 when billing an E/M visit separately from a preventive service on the same day. Make sure the documentation supports both services being distinct and separately necessary.
If your provider participates in VFC (Vaccines for Children) or similar state programs, billing errors can happen when vaccine products are incorrectly submitted to payers who don’t reimburse them.
How to avoid it:
Do not bill payers for vaccine products provided free by a state program. Only bill for the administration. Understand each payer’s policy on billing VFC-related services.
Billing codes for well visits, screenings, and vaccines often depend on the patient’s age. If billing systems aren’t updated when a child transitions into a new age category, claims can be rejected for invalid codes.
How to avoid it:
Double-check age-based coding rules regularly and review EHR or billing software alerts for upcoming birthday-based code changes.
Pediatric billing is full of small but critical details. From age-specific coding to vaccine tracking and coordination of benefits, small oversights can lead to frequent delays or denials. By setting up clear workflows, reviewing payer rules regularly, and training staff on the most common pitfalls, you can help pediatric providers stay compliant and get paid on time.