Pediatric Billing Services
Pediatric medical billing for well-child visits, vaccines, screenings, newborn care and Medicaid and CHIP claims. BilNow codes by age band and counselling note, so your pediatricians stay with patients and claims get paid.
98% First-Pass Claim Rate
Pediatric Billing
Of Collections, No Setup Fee
No setup fee · No long-term contract · HIPAA-trained staff
Pediatric Billing Services for General Pediatric Practices and Groups
Pediatric billing mixes calendar-driven well visits, same-day sick care, multi-component vaccines and heavy Medicaid and CHIP volume. One wrong age band or a missing counselling note changes the code and the payment. BilNow is a pediatrics billing company that bills for solo pediatricians, multi-provider groups and clinics that see children alongside adults.
Preventive and sick visits
Age-banded 99381–99395, with modifier 25 where a separate problem is treated.
Vaccines and VFC
90460–90461 or 90471–90474 chosen by age and counselling, and administration-only VFC claims.
Screenings
Developmental and emotional screening codes billed per standardized instrument.
Newborn care
Daily newborn codes 99460–99463 for hospital and birthing-center care and first visits elsewhere.
Medicaid and CHIP
EPSDT visits, state modifiers, managed-care plan rules and eligibility checks.
Family physicians who also treat children can read our family practice billing services page.
Preventive Visit Codes 99381–99395: Age Bands and Same-Day Sick Visits
Preventive medicine codes depend on the child’s age and on whether the child is a new or established patient. Billing the wrong band is an easy denial, especially around birthdays.
| Patient age | New patient | Established patient |
|---|---|---|
| Under 1 year | 99381 | 99391 |
| 1–4 years | 99382 | 99392 |
| 5–11 years | 99383 | 99393 |
| 12–17 years | 99384 | 99394 |
| 18–39 years | 99385 | 99395 |
When the provider finds and manages a significant, separate problem at a well visit, such as an ear infection or an asthma flare, the problem-oriented office visit goes on the claim with modifier 25, for example 99392 plus 99213-25. The note has to show the extra work, and minor findings are not billed separately. Some managed-care plans pay a reduced amount for the second visit, so we read each plan’s policy.
Diagnosis codes must agree with the visit: Z00.121 or Z00.129 for the well visit, and Z23 on vaccine lines.
Vaccine Administration: 90460 and 90461 vs 90471–90474
Two code families report giving a vaccine, and the choice turns on age and counselling. 90460 and 90461 apply through age 18 when a physician or other qualified health care professional counsels the family before the vaccine is given. They count components, not products: 90460 is the first or only component of each vaccine, and 90461 is each additional component. Tdap has three components, so it is billed as 90460 once and 90461 twice.
90471 to 90474 apply when that counselling is not documented or the patient is older than 18. 90471 is the first injectable vaccine and 90472 each additional one. 90473 is the first intranasal or oral vaccine and 90474 each additional one. Each vaccine product counts once, even a combination product. The vaccine itself has its own CPT code when the practice bought the dose.
We match the code family to the counselling note before the claim goes out. For more on the 90471 family, see our CPT 90471 vaccine administration billing guide.
Vaccines for Children (VFC): Bill the Administration, Not the Vaccine
The Vaccines for Children program supplies recommended vaccines at no cost to enrolled practices for eligible children, so the practice may not charge for the vaccine. It can bill an administration fee, which state Medicaid programs cap. It cannot turn away an eligible child because the family cannot pay that fee.
States differ on how a VFC claim is reported. Some require a modifier such as SL on the administration line, and some want the vaccine product code at a zero charge. We follow each state’s rule, so the vaccine is never billed at a price and the administration still pays.
VFC practices also screen and document each child’s eligibility category at every visit and report doses to the state immunization registry on the state’s deadline. We keep eligibility category and dose details consistent between the claim and your records.
Screening, Newborn and After-Hours Codes: 96110, 96127, 99460–99463, 99050 and 99051
These codes are billed beside the visit itself and carry their own documentation rules.
| Code | What it reports | Billing note |
|---|---|---|
| 96110 | Developmental screening, per instrument, with scoring and documentation | Autism screening at 18 and 24 months uses it too. Some Medicaid plans add a modifier. |
| 96127 | Brief emotional or behavioral assessment, per standardized instrument | Depression and similar questionnaires. One unit per instrument; plan age and tool lists vary. |
| 96161 | Caregiver-focused risk assessment, per instrument | Used for parent questionnaires at infant visits, such as a depression screen. |
| 99460 | Initial hospital or birthing-center care, normal newborn, per day | Once per day. |
| 99461 | Initial care, normal newborn seen outside a hospital or birthing center | First office or home visit. |
| 99462 | Subsequent hospital care, normal newborn, per day | Daily rounds. |
| 99463 | Initial hospital or birthing-center care, newborn admitted and discharged the same date | Same-day stays only. |
| 99050 | Office services outside regularly scheduled hours or when the office is closed | Reported with the visit. |
| 99051 | Office services during regularly scheduled evening, weekend or holiday hours | Added to the basic service, never alone. |
Several plans treat 99050 and 99051 as included in the visit payment, or exclude them with preventive visits, so we verify coverage by plan before an after-hours clinic budgets for them.
Medicaid, CHIP and EPSDT: State Rules, Eligibility and Credentialing
Medicaid and CHIP pay for a large share of pediatric visits, and each state runs them differently. Medicaid’s EPSDT benefit covers enrolled children under 21 with screening, vision, hearing and dental care, and the diagnosis and treatment of problems found. States set the periodicity schedule and may adopt Bright Futures. CHIP covers children in families whose income is too high for Medicaid but too low for private coverage, and a state may run it inside Medicaid or as a separate program.
The differences show up in claims: modifiers such as EP on EPSDT visits, accepted screening tools, form types and managed-care plan policies. Each Medicaid program and plan also requires enrollment, which our medical credentialing services team handles. Referrals and follow-up care found at EPSDT screens can need approval through our prior authorization services.
Eligibility checks come before the visit. Children’s coverage changes, some have two plans, and newborns may not yet be enrolled, so we verify benefits ahead of the visit and again at claim time. We also flag upcoming 18th birthdays, because the preventive code changes.
Common Pediatric Billing Denials and How We Prevent Them
Most pediatric denials come from a short list of causes, each fixable before the claim is sent.
Sick visit bundled into the well visit
Modifier 25 is missing, or the note does not show a separate problem. We check documentation before the claim leaves.
Age band or code family mismatch
The preventive code does not match the birth date, or 90460 is billed without counselling. Edits compare birth date, note and code.
VFC vaccine billed at a price
A free VFC dose carries a charge, or the administration line lacks the state’s modifier. We apply the state rule.
Screening lines denied
No instrument or score in the note, too many units, a tool the plan does not accept, or a missing diagnosis such as Z13.42.
Eligibility and newborn enrollment
Coverage is inactive, the wrong plan is billed or the baby is not yet on a plan. We re-verify and resubmit.
Frequency limits and late filing
A second preventive visit in the same period, or a claim sent after the payer’s deadline. We track both.
When a denial does arrive, our denial management services team works the appeal, and we watch each payer’s timely filing limits so no claim ages out.
How Our Pediatric Billing Workflow Runs and What It Costs
Eligibility check
We verify coverage, VFC category and plan rules before the visit.
Charge review
Visit, vaccine and screening lines are matched to the note.
Claim scrub
Age-band, modifier and VFC edits run before submission, which supports our 98% first-pass claim rate.
Submission
Claims go to each payer in its required format.
Payments and denials
Payments are posted and every denial is worked, keeping denials under 5%.
Reporting
You receive reports on collections, denials and open balances.
BilNow charges 2.7% of collections. There is no setup fee and no long-term contract, so you pay when your practice gets paid. Our HIPAA-trained staff work inside your existing system, and we support more than 100 EHRs.
Pediatric Billing FAQs
What do pediatric billing services include?
Pediatric billing services cover eligibility checks, charge review for preventive visits, vaccines, screenings and sick visits, claim scrubbing, submission, payment posting, denial follow-up and reporting. BilNow also handles Medicaid and CHIP rules, VFC claims, plan enrollment and appeals. Because pediatric claims depend on age, counselling notes and state rules, we check each claim against the documentation before it goes to the payer, while your staff keeps the clinical work.
Which codes are used for well-child visits, and can a sick visit be added?
Well-child visits use 99381 to 99385 for new patients and 99391 to 99395 for established patients, chosen by age: under 1, 1 to 4, 5 to 11, 12 to 17 and 18 to 39. If the provider manages a significant, separate problem during the visit, a problem-oriented office visit can be billed with modifier 25, and the note must show that separate work. Minor findings are not billed separately.
What is the difference between 90460 and 90471?
90460 and 90461 are for patients through age 18 when a physician or other qualified health care professional counsels the family before the vaccine. 90460 is the first component of each vaccine and 90461 each additional component, so Tdap is 90460 once plus 90461 twice. 90471 to 90474 apply without that counselling or for older patients, and count each vaccine product once. The code family has to match the note.
How are Vaccines for Children (VFC) vaccines billed?
VFC vaccines are supplied free to enrolled practices for eligible children, so the practice cannot charge for the vaccine. It bills the administration, up to the state’s fee cap, and cannot refuse an eligible child whose family cannot pay that fee. States differ on reporting, and some require a modifier such as SL on the administration line. Practices also document eligibility at each visit and report doses to the state registry.
How are developmental and behavioral screenings billed?
Developmental screening is billed with 96110 and brief emotional or behavioral assessments with 96127. Both are reported per standardized instrument, with scoring and documentation, so two instruments mean two units. Bright Futures places developmental screening at 9, 18 and 30 months and autism screening at 18 and 24 months. Plans differ on accepted tools, age limits and modifiers, and some expect a diagnosis such as Z13.42, so we check each plan’s list.
How are newborn care and after-hours visits billed?
Newborn care uses 99460 for initial hospital or birthing-center care per day, 99461 for initial care elsewhere, 99462 for subsequent hospital days and 99463 when the newborn is admitted and discharged the same date. After-hours visits can use 99050 outside scheduled hours or 99051 during scheduled evening, weekend or holiday hours, reported with the visit. Many plans treat these as included in the visit payment, so we verify coverage by payer first.
How do Medicaid and CHIP change pediatric billing?
Medicaid and CHIP differ by state in modifiers, accepted screening tools, forms and managed-care policies. Medicaid’s EPSDT benefit covers enrolled children under 21 with screening, vision, hearing, dental care and follow-up treatment on a state-set schedule. CHIP covers children in families above Medicaid income limits, and a state may run it inside Medicaid or separately. We follow each state’s manual and handle plan enrollment through our credentialing team.
What does pediatric billing cost with BilNow?
BilNow charges 2.7% of collections. There is no setup fee and no long-term contract, so the fee follows the money your practice collects. Our claims run at a 98% first-pass rate with denials under 5%, and our HIPAA-trained staff work inside your existing system across more than 100 EHRs. Contact us for a review of your payer mix and vaccine volume, and we will explain what billing would look like for your practice.
Prepared by the BilNow Editorial Team · Last updated October 2, 2026
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