Pediatric Medical Billing And Coding Guidelines - Accurate Reimbursement
Streamline pediatric billing and coding with expert precision. Ensure compliance with guidelines for accurate reimbursement and efficient practice management.
Pediatric Billing And Coding Guidelines
Pediatrics addresses children's physical, mental, and social health from birth to young adulthood, including a range of specializations.
Key areas of pediatric medical billing are neonatology, emergency pediatric medicine, critical care, cardiology, rheumatology, pulmonology, and developmental-behavioral.
Each field focuses on aspects of pediatric care, from premature infants to adolescents up to 18 years old, ensuring comprehensive health management across different stages of a child's development.
Pediatric Billing and Procedure Codes
Pediatric billing encompasses a range of codes specific to various age groups, including well-child visits, preventive care, and acute or chronic illness management. Procedure codes must reflect the complexity and scope of the services rendered, from routine immunizations and developmental screenings to more specialized treatments and evaluations. Accurate coding requires a thorough understanding of age-specific guidelines and each clinical encounter's nuances.
Common Pediatric Billing and Procedure Codes
Evaluation and Management (E&M) codes are crucial for documenting patient visits, with variations based on their complexity and duration. Preventive medicine codes are used for routine check-ups and vaccinations, ensuring proper health maintenance for children.
Procedure codes apply to pediatric-specific treatments and surgeries.
Below is a list of key codes:
- 99381-99384: Preventive health check-ups for new patients.
- 99391-99394: Preventive health check-ups for established patients.
- 54150: Circumcision using a clamp or similar device.
- 54160: Circumcision through surgical excision (excluding clamp, device, or dorsal slit) for neonates (up to 28 days old).
- 36510: Umbilical vein catheterization for diagnostic or therapeutic purposes in newborns.
- 90460: Administration of immunizations for individuals up to 18 years old by any route, including counseling from a physician or qualified healthcare professional; applies to the first or only component of each vaccine administered.
New Patient Pediatric Preventive Care Coding
A new patient is defined as someone who has not received any professional face-to-face services from physicians or qualified healthcare professionals (QHPs) within the past three years. This includes services rendered by the same speciality and subspecialty within the same group practice or by any other QHP.
There is a list of related CPT codes for new pediatric preventive care patients with ICD-10 codes for coding guidelines.
99381: Infant (younger than 1 year)
This code refers to the initial comprehensive preventive medicine evaluation and management for a new patient. It includes an age and gender-appropriate history, physical examination, counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of laboratory or diagnostic procedures. This code applies specifically to infants younger than 1 year of age.
Related ICD-10 Codes are:
- Z00.110: Health supervision for newborn under 8 days old.
- Z00.111: Health supervision for newborn 8 to 28 days old.
- Z00.121: Routine child health exam with abnormal findings.
- Z00.129: Routine child health exam without abnormal findings.
99382: Early childhood (age 1–4 years)
This code covers the initial comprehensive preventive medicine evaluation and management for a new patient, including an age- and gender-appropriate history, physical examination, counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of laboratory or diagnostic procedures. It is specifically for children aged 1 through 4 years.
Related ICD-10 codes are:
- Z00.121: Routine child health exam with abnormal findings
- Z00.129: Routine child health exam without abnormal findings
99383: Late childhood (age 5–11 years)
This code refers to the initial comprehensive preventive medicine evaluation and management for a new patient, including an age- and gender-appropriate history, physical examination, counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of laboratory or diagnostic procedures. It is applicable to children aged 5 through 11 years.
Related ICD-10 codes are:
- Z00.121: Routine child health exam with abnormal findings
- Z00.129: Routine child health exam without abnormal findings
99384: Adolescent (age 12–17 years)
This code covers the initial comprehensive preventive medicine evaluation and management for a new patient, which includes an age- and gender-appropriate history, physical examination, counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of laboratory or diagnostic procedures. It is specifically for adolescents aged 12 through 17 years.
Related ICD-10 Codes are:
- Z00.121: Routine child health exam with abnormal findings
- Z00.129: Routine child health exam without abnormal findings
Preventive Medicine Services for Established Patients
Comprehensive preventive medicine services for established patients involve a thorough evaluation and management that includes an age- and gender-appropriate history, physical examination, counseling, anticipatory guidance, risk factor reduction interventions, and ordering necessary laboratory or diagnostic procedures.
99391: Infant (younger than 1 year)
This code represents a periodic comprehensive preventive medicine reevaluation and management for an established patient. It includes an age- and gender-appropriate history, physical examination, counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of laboratory or diagnostic procedures. It applies specifically to infants younger than 1 year.
Related CPT-10 codes are:
- Z00.110: Health supervision for newborn under 8 days old.
- Z00.111: Health supervision for newborn 8 to 28 days old.
- Z00.121: Routine child health exam with abnormal findings.
- Z00.129: Routine child health exam without abnormal findings.
99392: Early childhood (age 1–4 years)
This code covers a periodic comprehensive preventive medicine reevaluation and management for an established patient in early childhood, aged 1 through 4 years. It includes an age- and gender-appropriate history, physical examination, counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of laboratory or diagnostic procedures.
Related CPT-10 codes are:
- Z00.121: Routine child health exam with abnormal findings.
- Z00.129: Routine child health exam without abnormal findings.
99393: Late childhood (age 5–11 years)
This code refers to a periodic comprehensive preventive medicine reevaluation and management for an established patient in late childhood, aged 5 through 11 years. It includes an age- and gender-appropriate history, physical examination, counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of laboratory or diagnostic procedures.
Related CPT-10 codes are:
- Z00.121: Routine child health exam with abnormal findings.
- Z00.129: Routine child health exam without abnormal findings.
99394: Adolescent (age 12–17 years)
This code covers a periodic comprehensive preventive medicine reevaluation and management for an established patient in adolescence, aged 12 through 17 years. It includes an age- and gender-appropriate history, physical examination, counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of laboratory or diagnostic procedures.
Related CPT-10 codes are:
- Z00.121: Routine child health exam with abnormal findings.
- Z00.129: Routine child health exam without abnormal findings.
Pediatric Medical Billing and Coding Guidelines For Normal Newborn Care
Proper billing for normal newborn care involves the use of specific CPT codes that address various scenarios of care provided. Here are the relevant codes:
- 99460: This code is used for the initial hospital or birthing center care per day, including the evaluation and management of a normal newborn infant.
- 99461: This code applies to initial care per day for the evaluation and management of a normal newborn infant when seen outside a hospital or birthing center.
- 99462: This code covers subsequent hospital care per day for the evaluation and management of a normal newborn.
- 99463: This code is for initial hospital or birthing center care per day for the evaluation and management of a normal newborn infant who is admitted and discharged on the same date.
Note: For newborn hospital discharge services provided on a date subsequent to the admission date, use codes 99238 or 99239.
Immunization Administration (IA) - Pediatric Codes
- 90460: This code is used for the immunization administration (IA) for patients through 18 years of age, via any route, with counseling by a physician or other qualified healthcare professional. It covers the first or only component of each vaccine or toxoid administered during the encounter.
- +90461: This add-on code is used to report each additional vaccine or toxoid component administered. It should be listed separately in addition to the primary code (90460). Components refer to all antigens within a vaccine that protect against diseases caused by a single organism. Combination vaccines, which contain multiple vaccine components, are considered as having a single component per organism.
Qualified Healthcare Professional (QHP)
This includes individuals who, by education, training, licensure, and payer policy, are qualified to perform and independently report professional services. Clinical staff work under supervision and do not report professional services independently.
Usage: Code 90460 is reported for the first or only component in a vaccine given during an encounter. Multiple instances of 90460 can be reported in a single office visit if multiple vaccines or components are administered. Code 90461, being an add-on, is used in conjunction with 90460 when additional components are administered in the same encounter.
Requirements: Pediatric IA codes (90460, 90461) are applicable only if:
- The patient is 18 years or younger.
- Face-to-face vaccine counseling is provided by a physician or other QHP.
Note: Clinical staff may administer the vaccine, but if the counseling requirement is not met or the patient is older than 18 years, report using non-age-specific IA codes (90471–90474) instead.
Non-Age-Specific Immunization Administration (IA) Codes
When billing for immunizations, it's essential to use the appropriate CPT and ICD-10-CM codes for the administration and the specific vaccine administered during a patient encounter. Here's a guide to the non-age-specific IA codes:
- 90471: Used for administering one vaccine (single or combination vaccine/toxoid) via percutaneous, intradermal, subcutaneous, or intramuscular injections. This code should not be reported with code 90473.
- +90472: This add-on code reports each additional vaccine (single or combination vaccine/toxoid) administered. It should be listed separately and used in conjunction with codes 90460, 90471, or 90473.
- 90473: Used for the administration of one vaccine (single or combination vaccine/toxoid) via intranasal or oral routes. This code should not be reported with code 90471.
- +90474: This add-on code is used to report each additional vaccine (single or combination vaccine/toxoid) administered via intranasal or oral routes. It should be listed separately and used in conjunction with codes 90460, 90471, or 90473.
Primary vs. Add-On Codes
Codes 90471 and 90473 are used for the first vaccine administered during an office visit. Codes 90472 and 90474 are add-on codes used in addition to the primary codes (90460, 90471, or 90473) if multiple vaccines are given during the visit.
Counseling and Administration
For patients 18 years or younger, if a physician or other qualified healthcare professional provides counseling on some vaccines but not others, report code 90460 (and 90461, if applicable) for the vaccines counseled on. Use codes 90472 or 90474, as appropriate, for vaccines not counseled on.
Single Administration Rule
Only one primary administration code (90471 or 90473) can be reported per visit, even if multiple vaccines are given.
For detailed scenarios and further guidance, refer to the illustrative vignettes in the full vaccine product code list.
Scenario 1 - Coding for Vaccine Administration for a 2-Month-Old Patient
A 2-month-old established patient comes in for a routine checkup. During this visit, the following vaccines are administered: Pentacel (DTaP-Hib-IPV), pneumococcal, and rotavirus. The physician provides counseling on all vaccines, consents are obtained, and the nurse administers them.
Step 1: Choose the Correct Evaluation and Management (E/M) Code
- Code: 99391
- Description: Preventive medicine service for an established infant (age younger than 1 year).
Step 2: Identify the Vaccine Product Codes
- 90698: Pentacel (DTaP-Hib-IPV)
- 90670: Pneumococcal vaccine
- 90680: Rotavirus vaccine (oral)
Step 3: Determine the Immunization Administration (IA) Codes
To select the appropriate IA codes, consider:
- Is the patient 18 years or younger?
- Did the physician or other qualified healthcare professional (QHP) perform face-to-face vaccine counseling?
If the answer to both questions is yes, select a code from the pediatric IA code family (90460, 90461). If the answer to one of the questions is no, select a code from the non–age-specific IA code family (90471–90474).
In this scenario, the answer to both questions is yes. Therefore, IA codes 90460 and 90461 will be reported.
Step 4: Assign the Appropriate ICD-10-CM Diagnosis Codes
ICD-10-CM code Z23 is used for encounters where vaccines are administered. This code applies to all vaccines given during the visit, including routine well-child visits.
Final Coding Summary
CPT Code | Description | Related ICD-10-CM Code | ICD-10 Description |
---|---|---|---|
99391 | Preventive medicine service for established infants | Z00.129 | Routine child health exam without abnormal findings |
90698 | Pentacel vaccine | Z23 | Encounter for immunization |
90670 | Pneumococcal vaccine | Z23 | Encounter for immunization |
90680 | Rotavirus vaccine | Z23 | Encounter for immunization |
90460 (×3) | Pediatric IA for Pentacel, pneumococcal, and rotavirus (first component) | Z23 | Encounter for immunization |
90461 (×4) | Pediatric IA for additional components of the Pentacel vaccine | Z23 | Encounter for immunization |
Scenario 2 - Coding for Immunizations for a 5-Year-Old Patient
A 5-year-old established patient visits the physician for an annual well-child examination. During the visit, the patient receives her first hepatitis A vaccine, the fifth dose of the DTaP vaccine, and the influenza vaccine. The physician provides vaccine counseling to the parents, discussing the risks and benefits before administering the vaccines.
Step 1: Select the Appropriate Evaluation and Management (E/M) Code
- Code: 99393
- Description: Preventive medicine service for an established patient aged 5 to 11
Step 2: Identify the Vaccine Product Codes
- 90633: Hepatitis A vaccine (pediatric/adolescent dosage, intramuscular use)
- 90700: DTaP vaccine (for use in individuals younger than 7 years)
- 90686: Influenza virus vaccine (quadrivalent, preservative-free, 0.5 mL dosage, intramuscular use)
Step 3: Determine the Immunization Administration (IA) Codes
To select the appropriate IA codes, consider:
- Is the patient 18 years or younger?
- Did the physician or other qualified healthcare professional (QHP) perform face-to-face vaccine counseling?
If the answer to both questions is yes, select a code from the pediatric IA code family (90460, 90461). If the answer to one of the questions is no,
select a code from the non–age-specific IA code family (90471–90474). In this scenario, the answer to both questions is yes. Therefore, IA codes 90460 and 90461 will be reported.
Since both conditions are met, use the pediatric IA codes:
- 90460: Immunization administration with counseling by a physician or QHP for the first component of each vaccine administered.
- 90461: Each additional vaccine component administered (used in conjunction with 90460).
Step 4: Assign the Appropriate ICD-10-CM Diagnosis Codes
ICD-10-CM code Z23 is used for encounters where vaccines are administered. This code applies to all vaccines given during the visit.
Final Coding Summary
CPT Code | Description | Related ICD-10-CM Code | ICD-10 Description |
---|---|---|---|
99393 | Preventive medicine service for an established patient age 5 to 11 years | Z00.129 | Routine child health exam without abnormal findings |
90633 | Hepatitis A vaccine | Z23 | Encounter for immunization |
90700 | DTaP vaccine | Z23 | Encounter for immunization |
90686 | Influenza virus vaccine | Z23 | Encounter for immunization |
90460 (×3) | Pediatric IA for hepatitis A, DTaP, and influenza vaccines (first component) | Z23 | Encounter for immunization |
90461 (×4) | Pediatric IA for additional components of the DTaP vaccine | Z23 | Encounter for immunization |
Note: Many payers prefer consolidated coding to avoid multiple line items of 90460 or 90461. If advised by payer policies, follow the alternative coding approach.
Hearing Screening Coding Guideline
Accurate coding for hearing screenings is essential for proper documentation and reimbursement. Various CPT codes reflect different types of hearing tests, from basic pure tone screenings to more comprehensive evaluations like tympanometry and otoacoustic emissions. Understanding the appropriate ICD-10-CM codes for these procedures ensures that each aspect of the hearing assessment is accurately represented and billed.
CPT Codes and Descriptions
92551: Screening test, pure tone, air only
- ICD-10-CM Codes
- Z00.121: Routine child health exam with abnormal findings
- Z00.129: Routine child health exam without abnormal findings
92552: Pure tone audiometry (threshold), air only
- ICD-10-CM Codes:
- Z00.121: Routine child health exam with abnormal findings
- Z00.129:Routine child health exam without abnormal findings
92567: Tympanometry (impedance testing)
- ICD-10-CM Codes:
- Z00.121: Routine child health exam with abnormal findings
- Z00.129: Routine child health exam without abnormal findings
Note: Tympanometry requires calibrated electronic equipment. Tests using alternative methods, like whispered voice or tuning fork, are not reported separately. If testing is performed on only one ear, include modifier 52.
92558: Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis
- ICD-10-CM Codes:
- Z00.110: Health supervision for newborns under 8 days old
- Z00.111: Health supervision for newborns 8 to 28 days old
- Z00.121: Routine child health exam with abnormal findings
- Z00.129: Routine child health exam without abnormal findings
- P09.6: Abnormal findings on neonatal screening
92588: Comprehensive diagnostic evaluation, with interpretation and report
92650: Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated analysis
92587: Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient evoked otoacoustic emissions, with interpretation and report
- ICD-10-CM Codes:
- Z01.10: Encounter for examination of ears and hearing without abnormal findings
- Z01.118: Encounter for examination of ears and hearing with other abnormal findings
Note: These codes apply when specific disorders are identified or confirmed. A follow-up visit may be necessary for failed hearing screenings, coded with 99212–99215. Use Z01.110 for hearing examinations following a failed screening when no specific disorder is identified. If there are other abnormal findings, include the code for the findings (e.g., R94.120 for abnormal auditory function study).
Vaccines for Children (VFC) Program Reporting Guidelines
The rules for reporting vaccines for patients eligible under the Vaccines for Children (VFC) program can vary significantly from state to state. Some states mandate the use of product codes, while others require IA codes. Additionally, some states may require the use of modifiers, whereas others do not. Currently, the VFC program does not recognize component-based vaccine counseling, which means CPT code 90461 is not reimbursed. The American Academy of Pediatrics is actively working to address this issue to ensure that pediatric providers are compensated for administering multiple-component vaccines.
It is crucial to check with your state Medicaid plan for specific rules, which may include the ability to report code 99211 alongside IA codes for vaccine-only encounters. Always obtain these rules in writing to ensure compliance.
Commonly Administered Pediatric Vaccines
Product Code | Vaccine | Manufacturer Brand | Number of Vaccine Components |
---|---|---|---|
90702 | Diphtheria and tetanus toxoids (DT), adsorbed for IM use in children under 7 years | SP Diphtheria and Tetanus Toxoids Adsorbed | 2 |
90700 | Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP) for IM use in children under 7 years | SP GSK DAPTACEL INFANRIX | 3 |
90696 | Diphtheria, tetanus toxoids, and acellular pertussis vaccine and inactivated poliovirus vaccine (DTaP-IPV) for IM use in children 4-6 years old | GSK SP KINRIX Quadracel | 4 |
90697 | Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, w PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB) for IM use | Merck/SP VAXELIS | 6 |
90698 | Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae type b, and inactivated poliovirus vaccine (DTaP-IPV/Hib) for IM use | SP Pentacel | 5 |
90723 | Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and inactivated poliovirus vaccine (DTaP-Hep B-IPV) for IM use | GSK PEDIARIX | 5 |
90633 | Hepatitis A vaccine (Hep A), pediatric/adolescent dosage, 2 dose, for IM use | GSK Merck HAVRIX VAQTA | 1 |
90740 | Hepatitis B vaccine (Hep B), dialysis or immunosuppressed patient dosage, 3 dose, for IM use | Merck RECOMBIVAX HB | 1 |
90743 | Hepatitis B vaccine (Hep B), adolescent, 2 dose, for IM use | Merck RECOMBIVAX HB | 1 |
90744 | Hepatitis B vaccine (Hep B), pediatric/adolescent dosage, 3 dose, for IM use | Merck GSK RECOMBIVAX HB ENERGIX-B | 1 |
90746 | Hepatitis B vaccine (Hep B), adult dosage, for IM use | Merck GSK RECOMBIVAX HB ENERGIX-B | 1 |
90747 | Hepatitis B vaccine (Hep B), dialysis or immunosuppressed patient dosage, 4 dose, for IM use | GSK ENERGIX-B | 1 |
90647 | Haemophilus influenzae type b vaccine (Hib), PRP-OMP conjugate, 3 dose, for IM use | Merck PedvaxHIB | 1 |
90648 | Haemophilus influenzae type b vaccine (Hib), PRP-T conjugate, 4 dose, for IM use | SP GSK ActHIB HIBERIX | 1 |
90651 | Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (HPV), 2 or 3 dose schedule, for IM use | Merck GARDASIL 9 | 1 |
90707 | Measles, mumps, and rubella virus vaccine (MMR), live, for subcutaneous use | Merck M-M-R II | 3 |
90710 | Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use | Merck ProQuad | 4 |
90619 | Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, tetanus toxoid carrier (MenACWY-TT), for IM use | SP MenQuadfi | 1 |
90620 | Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B (MenB-4C), 2 dose schedule, for IM use | GSK Bexsero | 1 |
90621 | Meningococcal recombinant lipoprotein vaccine, serogroup B, 2 or 3 dose schedule, for IM use | Pfizer Trumenba | 1 |
90734 | Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, diphtheria toxoid carrier (MenACWY-D) or CRM197 carrier(MenACWY-CRM), for IM use | SP GSK Menactra Menveo | 1 |
90670 | Pneumococcal conjugate vaccine, 13 valent (PCV13), for IM use | Pfizer PREVNAR 13 | 1 |
90732 | Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, for subcutaneous or IM use for ages 2 and older | Merck PNEUMOVAX 23 | 1 |
90713 | Poliovirus vaccine (IPV), inactivated, for subcutaneous or IM use | SP IPOL | 1 |
90680 | Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, for oral use | Merck RotaTeq | 1 |
90681 | Rotavirus vaccine, human, attenuated (RV1), 2 dose schedule, live, for oral use | GSK ROTARIX | 1 |
90714 | Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, for IM use in patients 7 years and older | MBL SP TDVAX TENIVAC | 2 |
90715 | Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), for IM use in patients 7 years and older | SP GSK ADACEL BOOSTRIX | 3 |
90716 | Varicella virus vaccine (VAR), live, for subcutaneous use | Merck VARIVAX | 1 |
90749 | Unlisted vaccine or toxoid | Please see CPT manual. | - |
90672 | Influenza virus vaccine, quad (LAIV), live, intranasal use | AstraZeneca Flumist Quad | 1 |
90674 | Influenza virus vaccine, quad (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for IM use | Seqirus Flucelvax | 1 |
90682 | Influenza virus vaccine, quad (RIV4), derived from recombinant DNA, HA protein only, preservative and antibiotic free, for IM use | Seqirus Flublok Quad | 1 |
90685 | Influenza virus vaccine, quad (IIV4), split virus, preservative free, 0.25ml dose, for IM use | Seqirus GSK SP Afluria Fluarix Fluzone Quad | 1 |
90686 | Influenza virus vaccine, quad (IIV4), split virus, preservative free, 0.5ml dosage, for IM use | Seqirus GSK SP Afluria FLUARIX Quad FLULAVAL Fluzone Quad | 1 |
90687 | Influenza virus vaccine, quad (IIV4), split virus, 0.25ml dosage, for IM use | Seqirus SP Afluria Quad Fluzone Quad | 1 |
90688 | Influenza virus vaccine, quad (IIV4), split virus, 0.5ml dosage, for IM use | Seqirus SP Afluria Fluzone Quad | 1 |
90756 | Influenza virus vaccine, quad (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for IM use | Seqirus Flucelvax Quad | 1 |
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