Essential Pediatric CPT Codes Every Biller Should Know
Stay up-to-date with the latest pediatric CPT and ICD-10 codes for 2025. Learn about essential preventive care, chronic care management, telemedicine, and more!
Pediatric Billing & Coding Alert
Pediatric medical billing refers to the process of managing the billing and payment for healthcare services provided to children. This involves the accurate coding of pediatric-specific diagnoses, treatments, and services to ensure proper reimbursement from insurance companies. The 2025 updates AMA to pediatric CPT codes include key changes, including new telemedicine codes, updates for immunizations, and additions for contraception services.
These updates reflect advancements in pediatric care and the growing importance of telemedicine. Pediatric billing requires a thorough understanding of these evolving codes, guidelines, and regulatory standards to ensure compliance and accurate claim submission. Staying updated on these changes helps healthcare providers receive timely and accurate reimbursement for the services they deliver to pediatric patients.
Latest Pediatric CPT Codes for 2025
The latest pediatric CPT codes for 2025 include a comprehensive range of services to ensure accurate billing for preventive care, counseling, and chronic care management in children and adolescents. Key codes include:
Preventive Care
- 99381–99385: Initial comprehensive preventive evaluations for new patients, categorized by age from infants to adults (18+).
- 99391–99395: Established patient preventive care for various age groups, including infants, children, and adolescents.
Counseling Services
- 99401–99404: Preventive counseling services for risk reduction, with varying durations (15 to 60 minutes).
- 99411: Group counseling for preventive medicine or risk reduction.
Chronic Care Management
- 99491–99437: Chronic care management codes, offering time-based billing for first 30 minutes or additional care.
These updated codes ensure pediatric healthcare providers can accurately document and receive reimbursement for services provided to young patients.
Pediatrician’s Evaluation & Management CPT Codes
Pediatricians often encounter children with acute illnesses, follow-up needs, or chronic conditions requiring management. Accurate coding depends on the patient’s status (new vs. established) and the complexity of the visit.
New Patient Codes (99202–99205)
These codes are used when a child is seen for the first time for a non-preventive service. The level depends on medical decision-making (MDM) or time spent:
- 99202: Straightforward MDM, ~15–29 minutes.
- 99203: Low MDM, ~30–44 minutes.
- 99204: Moderate MDM, ~45–59 minutes.
- 99205: High MDM, ~60–74 minutes.
Established Patient Codes (99212–99215)
For patients returning to the practice for non-preventive services, these codes reflect the level of MDM or time:
- 99212: Straightforward MDM, ~10–19 minutes.
- 99213: Low MDM, ~20–29 minutes.
- 99214: Moderate MDM, ~30–39 minutes.
- 99215: High MDM, ~40–54 minutes.
Emergency Department Visits (99281–99285)
Pediatricians providing care in emergency settings need to use specific codes for ED visits based on complexity:
- 99281: Minor problems requiring minimal MDM.
- 99282: Low MDM for issues like mild asthma or simple injuries.
- 99283: Moderate MDM, such as for persistent high fever or moderate dehydration.
- 99284: High MDM for conditions like severe respiratory distress.
- 99285: Critical cases with immediate threats to life, such as sepsis or severe trauma.
Consultation Codes (99242–99245)
When a pediatrician is asked to evaluate a patient and provide recommendations for a specific problem, consultation codes should be used:
- 99242: Straightforward MDM, ~20 minutes.
- 99243: Low MDM, ~30 minutes.
- 99244: Moderate MDM, ~40 minutes.
- 99245: High MDM, ~55 minutes.
Critical Care Services (99291–99292)
For life-threatening conditions requiring immediate and continuous attention, pediatric critical care codes should be used:
- 99291: First 30–74 minutes of critical care.
- 99292: Each additional 30 minutes.
Vaccine Administration Codes
These codes are used to document the administration of vaccines, including the work involved in counseling the patient/family, administering the vaccine, and observing the patient afterward.
- 90460: Administration of the first or only vaccine component, with counseling.
- 90461: Each additional vaccine/toxoid component, with counseling.
- 90471: Administration of one vaccine, without counseling.
- 90472: Each additional vaccine, without counseling.
- 90473: Single vaccine administration by intranasal or oral route, without counseling.
- 90474: Each additional vaccine administered by intranasal or oral route, without counseling.
Vaccine Product Codes
These codes represent the vaccine product itself, billed separately. Common pediatric vaccine product codes include:
- 90696: DTaP-IPV (Kinrix).
- 90698: DTaP-Hib-IPV (Pentacel).
- 90723: DTaP-Hep B-IPV (Pediarix).
- 90633: Hepatitis A (2-dose series).
- 90647: Haemophilus influenzae type b (Hib).
- 90707: MMR (Measles, Mumps, Rubella).
- 90680: Rotavirus (oral, 3-dose series).
- 90713: Polio (IPV).
- 90716: Varicella (chickenpox).
- 90686: Quadrivalent flu vaccine (preservative-free).
- 90672: Intranasal live attenuated influenza vaccine.
- 90651: HPV vaccine (9-valent).
Pediatric ICD-10 Codes For Medical Billing
The following ICD-10 Codes are for pediatric care:
Z00.110 - Health Examination for Newborn Under 8 Days Old
This code is used for a health examination of a newborn who is under 8 days old.
- Parent Code: Z00.11
- Exclusion 1: Does not apply to health checks for children over 28 days old (refer to Z00.12 and onward).
- Additional Note: If there are any abnormal findings during the examination, use an additional code to specify them.
- Parent Code Notes: Z00
- Exclusion 1: Does not apply to examinations conducted for administrative purposes (refer to Z02.-).
- Exclusion 2: Does not apply to examinations conducted before procedures (refer to Z01.81 and onward).
- special screening examinations (Z11-Z13)
Z00.111 - Health Examination for Newborn Aged 8 to 28 Days
This code is used for the health examination of a newborn between 8 and 28 days old, including checks such as weight assessments.
- Parent Code: Z00.11
- Exclusion 1: Does not apply to health checks for children older than 28 days (refer to Z00.12 and onward).
- Additional Note: Use an additional code if any abnormal findings are identified.
- Parent Code Notes: Z00
- Exclusion 1: Does not apply to examinations performed for administrative purposes (refer to Z02.-).
- Exclusion 2: Does not apply to examinations before procedures (refer to Z01.81 and onward) or special screening examinations (codes Z11-Z13).
Z00.121 - Encounter for Routine Child Health Examination with Abnormal Findings
This code is used when a routine health examination is conducted for a child and abnormal findings are identified. An additional code should be used to specify the nature of the abnormal findings.
- Parent Code: Z00.12
- Exclusion 1: Does not apply to health checks for children under 29 days old (refer to Z00.11 and onward).
- Exclusion 2: Does not apply to health supervision for foundlings or other healthy infants or children (refer to Z76.1-Z76.2) or newborn health examinations (refer to Z00.11 and onward).
- Parent Code Notes: Z00
- Exclusion 1: Does not apply to examinations performed for administrative purposes (refer to Z02.-).
- Exclusion 2: Does not apply to examinations before procedures (refer to Z01.81 and onward) or special screening examinations (codes Z11-Z13).
Z00.129 - Encounter for Routine Child Health Examination Without Abnormal Findings
This code is used for a routine health examination of a child where no abnormal findings are identified. It can also be used for routine health exams for children when no specific abnormal findings are noted.
- Parent Code: Z00.12
- Exclusion 1: Does not apply to health checks for children under 29 days old (refer to Z00.11 and onward).
- Exclusion 2: Does not apply to health supervision for foundlings or other healthy infants or children (refer to Z76.1-Z76.2) or newborn health examinations (refer to Z00.11 and onward).
- Parent Code Notes: Z00
- Exclusion 1: Does not apply to examinations performed for administrative purposes (refer to Z02.-).
- Exclusion 2: Does not apply to pre-procedural examinations (refer to Z01.81 and onward) or special screening examinations (codes Z11-Z13).
Z00.00 - Encounter for General Adult Medical Examination Without Abnormal Findings
This code is used for a general adult medical examination when no abnormal findings are identified. It can also be used for an adult health check-up with no noted issues.
- Parent Code: Z00.0
- Exclusion 1: Does not apply to examinations for signs or symptoms (use codes for the specific sign or symptom). Does not apply to general health check-ups for infants or children (refer to Z00.12 and onward).
- Parent Code Notes: Z00
- Exclusion 1: Does not apply to examinations performed for administrative purposes (refer to Z02.-).
- Exclusion 2: Does not apply to pre-procedural examinations (refer to Z01.81 and onward) or special screening examinations (codes Z11-Z13).
Z00.01 - Encounter for General Adult Medical Examination With Abnormal Findings
This code is used when a general adult medical examination reveals abnormal findings. Additional codes should be used to specify the abnormal findings.
- Parent Code: Z00.0
- Exclusion 1: Does not apply to examinations for signs or symptoms (use codes specific to the sign or symptom). Does not apply to general health check-ups for infants or children (refer to Z00.12 and onward).
- Parent Code Notes: Z00
- Exclusion 1: Does not apply to examinations performed for administrative purposes (refer to Z02.-).
- Exclusion 2: Does not apply to pre-procedural examinations (refer to Z01.81 and onward) or special screening examinations (codes Z11-Z13).
BillingFreedom Specialized In Pediatric Medical Billing And Boost Revenue
BillingFreedom is dedicated to offering specialized pediatric medical billing services designed to enhance revenue for pediatric practices. With in-depth knowledge of pediatric coding, insurance requirements, and billing regulations, we streamline the billing process, reduce claim denials, and ensure timely reimbursement.
Our team is experienced in handling the complexities of pediatric care, from routine exams to specialized treatments, making sure all claims are accurately processed. By improving operational efficiency and maximizing reimbursements, BillingFreedom helps pediatric practices focus on delivering quality care while boosting their financial health.
For more details about our exceptional medical billing services, please don't hesitate to email us at info@billingfreedom.com or call us at +1 (855) 415-3472.
Ready to Boost Your Revenue?
Save your hard earned money, register, before it's gone.