Age-specific errors in pediatric CPT codes cost practices thousands monthly, yet they’re completely preventable once you know the exact cutoffs. Bill a five-year-old’s checkup with an infant code, and watch your claim get rejected within 48 hours. Use 99382 instead of 99383 for that same visit, and you’ve just underbilled by $30.
Pediatric billing and coding spans four distinct age ranges. Each has its own set of preventive codes, documentation requirements, and reimbursement rates. This guide breaks down every age category so you can stop second-guessing code selection and start capturing what you’ve earned.
Understanding Age-Based Pediatric CPT Code Structure
Pediatric CPT codes are split into four distinct age brackets because a child’s healthcare needs shift dramatically from infancy through adolescence. The American Medical Association designed these ranges to reflect the different levels of complexity, time, and clinical focus required at each developmental stage.
Here’s the framework every pediatric billing services provider works with:
The Four Age Categories:
- Infant (birth to under 1 year)
- Early childhood (1-4 years)
- Late childhood (5-11 years)
- Adolescent (12-17 years)
Infant Pediatric CPT Codes (Birth to Under 1 Year)
For routine well-baby checkups, you’ll use one of two codes depending on patient status:
CPT Code 99381
Initial comprehensive preventive medicine evaluation for a new patient infant (younger than 1 year). This covers the complete history, age-appropriate physical exam, anticipatory guidance for parents, and ordering of any necessary screening tests. You’ll typically use this for a baby’s first visit to your practice.
99391 CPT Code
Periodic preventive medicine reevaluation for an established patient infant (younger than 1 year). This applies to all subsequent well visits, the two-month, four-month, six-month, nine-month, and twelve-month checkups that established patients return for.
Important Note:
Both codes include measurements like length, weight, head circumference, and developmental screening. The comprehensive exam at this age focuses on infant-specific concerns: feeding patterns, sleep safety, motor skill development, and parent-infant bonding.
Newborn Hospital Care Codes
Hospital-based infant care uses an entirely different set of codes from the well child CPT codes above:
99460 CPT Code
Initial hospital or birthing center care, per day, for evaluation and management of a normal newborn infant. The 99460 CPT code description specifies this is for the first day of life when the baby is assessed immediately after birth. You bill this once per day, so a three-day hospital stay means three separate 99460 charges.
CPT 99461 Code
Initial care per day for evaluation and management of a normal newborn seen outside a hospital or birthing center. This applies when babies are born at home or in alternative settings, and the pediatrician provides the initial assessment there
CPT 99462 Code
Subsequent hospital care per day for evaluation and management of a normal newborn. Use this starting on day two of the hospital stay through discharge.
CPT 99463 Code
Initial hospital or birthing center care per day for a normal newborn admitted and discharged on the same date. This applies when a baby is born and goes home within the same calendar day.
Early Childhood Pediatric CPT Codes (Ages 1-4 Years)
Once a child celebrates their first birthday, the coding shifts to the early childhood category. This age range represents one of the busiest periods in pediatric billing services, with frequent well visits, an aggressive vaccination schedule, and high sick visit volume.
Core Preventive Codes
| Patient Status | CPT Code | When to Use |
|---|---|---|
| New Patient | 99382 | First visit to your practice for ages 1-4 |
| Established Patient | $99,392 | Routine checkups: 12M, 15M, 18M, 24M, 30M, and annual visits |
The exam focus shifts from infant reflexes to complex developmental milestones. You’re documenting speech patterns, social interactions, fine and gross motor skills, and behavioral concerns like tantrums or sleep resistance.
Sick Visit and Problem-Focused Codes
Early childhood sees the highest concentration of sick visits in pediatric coding. Ear infections, upper respiratory infections, and viral illnesses bring these kids back repeatedly between preventive visits.
| CPT Code | Level | Typical Time | Medical Decision-Making |
|---|---|---|---|
| 99202 | New patient, Level 2 | 15-29 min | Straightforward |
| 99203 | New patient, Level 3 | 30-44 min | Low complexity |
| 99204 | New patient, Level 4 | 45-59 min | Moderate complexity |
| 99212 | Established, Level 2 | 10-19 min | Straightforward |
| 99213 | Established, Level 3 | 20-29 min | Low complexity |
| 99214 | Established, Level 4 | 30-39 min | Moderate complexity |
Screening and Ancillary Services
These codes are separately billable from preventive visits when performed and documented. Developmental screening with 96110 requires the use of validated tools like the M-CHAT or ASQ.
| Service | CPT Code | Description |
|---|---|---|
| Developmental screening | 96110 | Standardized autism/developmental screening instruments |
| Behavioral assessment | 96127 | Brief emotional/behavioral assessment |
| Vision screening | 99173 | Instrument-based screening with quantitative results |
| Vision screening | 99177 | Instrument-based automated screening |
| Hearing screening | 92551 | 2Pure tone audiometry screening |
| Hearing screening | 92552 | Pure tone audiometry, air only |
| Fluoride varnish | 99188 | Topical fluoride application by physician |
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Vaccine Administration Codes
Vaccination administration peaks during these years. The pediatric CPT codes list for vaccine administration uses component-based billing for patients under 18.
| CPT Code | Description | Units to Bill |
|---|---|---|
| 90460 | First or only component, with counseling | One per vaccine administered |
| 90461 | Each additional component, with counseling | One per additional component |
| 90471 | Vaccine admin without counseling | One for first vaccine |
| 90472 | Additional vaccine without counseling | One per additional vaccine |
Preventive Counseling Codes
Time-based counseling, separate from the preventive visit, uses these codes:
| CPT Code | Duration | Use Case |
|---|---|---|
| 99401 | 15 minutes | Nutrition, safety, behavior topics |
| 99402 | 30 minutes | Extended counseling sessions |
| 99403 | 45 minutes | Complex behavioral interventions |
| 99404 | 60 minutes | Intensive risk reduction counseling |
These cannot be billed with preventive visit codes on the same day. If counseling occurs during a well visit, it’s included in 99382/99392.
Late Childhood CPT Codes (Ages 5-11 Years)
The five to eleven age range marks the school years, where preventive care shifts toward screenings, sports physicals, and behavioral health assessments. Kids in this bracket visit less frequently for illness but require specific documentation for school and athletic participation.
Core Preventive Codes
| Patient Status | CPT Code | Age Range | Typical Use |
|---|---|---|---|
| New Patient | 99383 | 5-11 years | First visit to practice |
| Established Patient | 99393 | 5-11 years | Annual checkups |
The 99393 CPT code description includes age-appropriate history, physical examination, anticipatory guidance, and risk factor counseling. These visits now incorporate school performance discussions, social development, and physical activity assessments.
School and Sports Physicals
Many parents schedule well visits specifically for school or sports clearance. The cpt code for a school physical is still 99383 or 99393, there’s no separate code for this purpose
| Condition | Typical Code | Complexity Level |
|---|---|---|
| Strep throat, URI, ear infection | 99213 | Low |
| Asthma exacerbation | 99214 | Moderate |
| ADHD follow-up | 99213-99214 | Low to moderate |
| Minor injury evaluation | 99213 | Low |
Screening and Behavioral Assessments
Behavioral health screening becomes critical in this age group. Mental health concerns like anxiety and depression start emerging, making 96127 one of the most commonly billed ancillary codes.
| Service | CPT Code | Purpose |
|---|---|---|
| Vision screening | 99173, 99177 | Required for school entry in most states |
| Hearing screening | 92551, 92567 | Pure tone or tympanometry |
| Behavioral/emotional assessment | 96127 | ADHD, anxiety, depression screening |
| Developmental screening | 96110 | Used less frequently than younger ages |
Minor Procedures
| Procedure | CPT Code | Common Scenarios |
|---|---|---|
| Wart destruction | 17110, 17111 | Plantar or common warts |
| Cerumen removal | 69210 | Impacted earwax |
| Foreign body removal, ear | 69200 | Small objects lodged in ear canal |
| Laceration repair, simple | 12001-12007 | Playground injuries |
Vaccine Administration
This age group receives fewer vaccines but still requires accurate component coding:
- Tdap booster (11-12 years): 90460 x 1, 90461 x 2 (three components)
- HPV series (11-12 years): 90460 x 1 (single component)
- Meningococcal (11-12 years): 90460 x 1 (single component)
- Influenza (annual): 90460 x 1 (single component)
ADHD Management Visits
ADHD follow-ups are frequent in late childhood. These are problem-focused visits, not preventive care, typically coded 99213 or 99214 depending on medication adjustments and symptom management complexity.
When parents bring up ADHD concerns during an annual checkup, you can bill both the preventive code (99393) and a sick visit code with modifier 25 if you’re doing significant additional evaluation beyond screening.
Adolescent CPT Codes (Ages 12-17 Years)
Adolescent care introduces unique billing considerations around confidentiality, mental health screening, and transition planning. The 99394 CPT code and its new patient counterpart become the foundation for annual visits that now include private discussions with the teen.
Core Preventive Codes
| Patient Status | CPT Code | Age Range | Key Features |
|---|---|---|---|
| New Patient | 99384 | 12-17 years | First comprehensive adolescent exam |
| Established Patient | 99394 | 12-17 years | Annual checkups with confidential component |
The CPT codes 99384 and 99394 visits must include time alone with the adolescent to discuss sensitive topics. Document this separate interview time clearly, it’s what distinguishes adolescent preventive care from younger age groups.
Confidential Health Topics
Documentation for adolescent visits requires careful attention to what stays confidential versus what’s shared with parents. You’re addressing substance use, sexual activity, mental health, and risk behaviors directly with the teen.
Billing note
The preventive code covers this counseling. Don’t separately bill time-based counseling codes (99401-99404) for discussions that occur during the preventive visit.
Mental Health and Behavioral Screening
| Service | CPT Code | Purpose |
|---|---|---|
| Depression screening | 96127 | PHQ-9 or similar validated tools |
| Anxiety screening | 96127 | GAD-7 administration and interpretation |
| Substance abuse screening | 96160 | Health risk assessment administration |
| ADHD rating scales | 96127 | Ongoing monitoring for established diagnosis |
Mental health screening becomes mandatory in this age group for most payers. The 96127 code is separately billable from the preventive visit when using validated instruments.
Adolescent Vaccine Schedule
| Service | CPT Code | Purpose |
|---|---|---|
| Tdap booster (11-12 years) | 3 | 90460 x 1, 90461 x 2 |
| HPV series (11-12 years, 3 doses) | 1 | 90460 x 1 |
| Substance abuse screening | 96160 | Health risk assessment administration |
| Meningococcal conjugate | 1 | 90460 x 1 |
| Meningococcal B (16-18 years) | 1 | 90460 x 1 |
| COVID-19 | Varies | 90460 x 1 |
Sports Physicals and School Requirements
Sports participation exams peak in adolescence. Like younger ages, there’s no separate sports physical code, use 99384 or 99394 for comprehensive exams that meet sports clearance requirements.
If the visit is solely for athletic clearance with a limited scope, consider using 99212-99214 instead. Document whether this is a comprehensive preventive visit or a focused sports physical.
Vaccine Administration Across All Age Groups
Vaccine billing is where most pediatric coding errors happen. The system uses component-based coding for patients under 18, which means you’re counting antigens, not injections. Get this wrong and you’re leaving significant revenue uncollected.
Component-Based Coding Structure
| CPT Code | Description | Age Restriction | Once per vaccine administered |
|---|---|---|---|
| 90460 | First or only component, with counseling | Under 18 only | Once per vaccine administered |
| 90461 | Each additional component, with counseling | Under 18 only | Per additional antigen in vaccine |
| 90471 | First vaccine, without counseling | Any age | When no counseling provided |
| 90472 | Additional vaccine, without counseling | Any age | Each additional vaccine |
For 90460 and 90461 to apply, you must document face-to-face counseling with the patient or caregiver about risks, benefits, and side effects. Without this documentation, you can only bill 90471-90472.
Counting Components Correctly
A component is each antigen that prevents disease from one organism. Here’s where practices commonly miscalculate:
| Vaccine | Total Components | How to Bill |
|---|---|---|
| Hepatitis A | 1 | 90460 x 1 |
| Varicella | 1 | 90460 x 1 |
| MMR (Measles, Mumps, Rubella) | 3 | 90460 x 1, 90461 x 2 |
| DTaP (Diphtheria, Tetanus, Pertussis) | 3 | 90460 x 1, 90461 x 2 |
| Pentacel (DTaP + Hib + IPV) | 5 | 90460 x 1, 90461 x 4 |
| Influenza | 1 | 90460 x 1 |
| HPV | 1 | 90460 x 1 |
Conclusion
Age-specific pediatric CPT codes aren’t arbitrary categories, they’re built around developmental stages that directly affect how you document, bill, and get paid. When you match the right code to the right age bracket, the claims process is clean, and revenue flows without the constant back-and-forth of denials and resubmissions.
The practices that master this coding structure spend less time fixing rejected claims and more time seeing patients. Whether you’re billing newborn hospital care with 99460 or annual adolescent checkups with 99394, precision at the front end eliminates problems at the back end. Set up your systems to flag age transitions, train staff on component-based vaccine billing, and document that every claim will get audited.
