As a pediatric billing company, we manage everything from age-specific coding to complex vaccination billing. We help you achieve accurate payments for rendered services. Reduce pediatric billing challenges, improve revenue cycle management process, and maximize reimbursements with our experts.
Book A Free ConsultationAdvances in pediatric care in recent years have improved outcomes for young patients, but they have also brought new and more complex billing requirements from age-specific coding and vaccine administration to VFC, CHIP, and Medicaid rules. Outsourcing to an experienced pediatric billing service has proven to increase revenue and reduce stress, so your team can stay focused on the kids instead of the claims.
96%
Collection Ratio
98.5%
First Pass Clean Claims Rate
Up to 35%
Revenue Increase
35%
Reduction in A/R
Running a pediatric office means your staff needs to stay focused on young patients who need extra care and attention. Between managing siblings in the waiting room, preventing the spread of contagious illnesses, and keeping wait times short, your team already has its hands full.
That’s where our pediatric revenue cycle management (RCM) services make a real difference. Your front desk and medical staff shouldn’t have to worry about complicated coding changes, pediatric insurance verification, or claim denials on top of everything else. When you partner with our specialists who handle medical billing for pediatrics, your team can do what they do best: take care of kids, while we handle getting you paid correctly and on time.
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Whether you run an independent pediatric practice or work within a larger healthcare institution, several factors make pediatric billing and coding uniquely complex and demanding. We help streamline your pediatric revenue cycle process and minimize claim denials.
No other specialty deals with as many vaccinations as pediatrics. That means your billing staff needs to know the right pediatric CPT codes for dozens of different vaccines, plus all the combination options. Some vaccines are required for school entry, others are just recommended, and parents need help keeping track of which is which.
Then there’s flu season, back-to-school time, and other periods when vaccine appointments stack up. Your team has to code everything correctly using the right pediatric CPT codes while managing the rush. Getting these claims right the first time matters because even small mistakes lead to denials.
Government programs like VFC, CHIP, and EPSDT help kids get the care they need. But each one has its own rules about what you can bill, how to document it, and what reports you need to file. Your practice might give a vaccine through VFC to one patient and bill private insurance for the same vaccine given to another patient.
Missing paperwork or billing something the wrong way can mean audits or losing money you’ve earned. Most practices don’t have time to stay on top of all these programs while seeing patients. That’s where working with pediatric billing services like MedCare helps. We know these programs inside and out and make sure you get paid correctly.
Here’s something that trips up a lot of practices: when a patient turns 18, everything changes for billing purposes. Insurance companies immediately treat them as adults, even if they’re still in high school, seeing the same pediatrician. The codes you’ve been using for years suddenly don’t work anymore.
A well-child visit now moves from the 12–17 preventive codes (99384/99394) to the 18–39 range (99385/99395), and the diagnosis shifts from the child-health-exam code Z00.129 to an adult preventive code (Z00.00/Z00.01). Same exam, different codes and with patients at every age, it’s easy to miss a birthday and submit the wrong one. MedCare MSO’s specialized pediatric medical billing services track these changes so you don’t end up with denials over something this simple.
Kids’ families move around more than you’d think. Parents change jobs and insurance plans, families relocate, and divorced parents often have different coverage for the same child. All of that creates headaches when patient information doesn’t match what’s in the insurance company’s system.
Even small mismatches (a slightly wrong address, an old policy number) get claims rejected immediately. Your clinical staff shouldn’t spend their time tracking down correct information and resubmitting claims. That’s not what they trained for. When you choose professional pediatric billing solutions, our billing experts catch these issues upfront and handle rejections fast so your revenue keeps flowing.
Vaccine coding, program rules, the age-18 flip, family coverage changes, every challenge above is a place claims quietly die. Our team finds the leaks and fixes the process behind them.
Get a Free Billing ReviewWe provide comprehensive pediatric billing and RCM services to help pediatric practices improve financial health. We follow the best practices in providing medical billing services to all types of practices. Our pediatric RCM services include:
We understand the mechanism of pediatric eligibility. So, we help verify eligibility in cases where babies are born but not added into the parent's insurance policy. Also, we manage the eligibility cases where children carry two plans.
Pediatric prior authorization clusters are managed by our expert teams. We manage prior authorizations around ADHD evaluations and speech therapy.
Our pediatric coding team knows that the codes are based on age categories. We take care of it in all types of codes across CPT/ICD-10/HCPCS.
Our claim scrubbing team efficiently catches errors in the claims before they reach payers.
We reconcile the electronic remittances (ERA/EFT) to keep accurate records.
We find the actual causes of claim denials instead of just resubmitting them.
Our dedicated team of A/R experts chase old claims and help recover revenue systematically to bring your days in A/R down.
Our healthcare credentialing services help new pediatric practices submit claims to payers from the first day.
You get fewer front desk calls once we handle your pediatric billing and send clear bills to parents.
Advanced reporting related to denials, collections, and A/R so you know where your pediatric practice stands.
From newborn eligibility to A/R recovery, we run your pediatric revenue cycle end to end.
Schedule a CallbackPediatric coding is driven by the child’s age, the type of visit, and whether counseling or a separate problem was addressed. These are the code families our team works with every day:
| Service / scenario | Code(s) | Key Rule |
|---|---|---|
| Well-child visit, new patient | 99381–99385 | Selected by age band |
| Well-child visit, established | 99391–99395 | Same age bands, established patient |
| Office / outpatient E/M | 99202–99215 | New vs established; by MDM or time |
| Vaccine admin with counseling (≤18) | 90460 / +90461 | First vs each additional component |
| Vaccine admin without counseling / >18 | 90471–90474 | By route: injectable vs oral/intranasal |
| Developmental / behavioral screening | 96110 / 96127 | Standardized instrument |
| Newborn care | 99460–99463 | Initial / subsequent / same-day / non-facility |
| Same-day well + sick visit | Modifier 25 | Appended to the problem E/M |
| Well-child diagnosis | Z00.129 (Z00.121 if abnormal) | Links the diagnosis to the preventive service |
| Immunization diagnosis | Z23 | For vaccine encounters |
Every vaccine has two claims and accurate billing is what helps to get accurately paid. Our experts are knowledgeable about the pediatric billing complexities.
We know that each vaccine claim is two claims, one for the product and the other for administration. If you miss either, the claim gets denied. The product is identified by its NDC (National Drug Code). When the physician counseling occurs, CPT 90460 is used for the first component and 90461 for additional units. It is done through age 18.
Under the VFC (Vaccines for Children) federal program, the vaccine is free, but the administration is billed to the payer, with the patient's VFC eligibility noted on each claim. We know that CPT 90460 does not apply when there is no counseling and a code family 90471-90474 is used. Our pediatric billers and coders check every claim thoroughly.
The diagnosis must be pointed towards the service and our medical billing team knows that. Z23 for immunization visits, Z00.129 when the shot rides a well-child exam. A same-day sick visit stays payable with modifier 25 on the E/M.
98.5%
Clean Claims
Many pediatric practices leave 90461s unbilled on combination vaccines, small amounts that compound into real revenue across a flu season. We check, and we fix it.
Talk to an Expert35%
Reduction in A/R
Pediatric billing outsourcing is simple with MedCare MSO. You can keep the EHR you already use including widely used pediatric platforms such as eClinicalWorks, and athenahealth, while your team documents in the system it knows. If you’d rather bring charting and billing together, practices can move to HealUS EHR, built under the supervision of MedCare MSO’s expert billers. Either way, we ensure compliance with regulatory requirements and protect patient data with HIPAA-compliant software.
Get Started TodayAs a pediatric billing company, we are aimed at helping pediatric practices get accurate payments. Our billers and coders are well-versed about the relevant CPT and diagnostic codes to help grow revenue.
With our complete understanding of the pediatric specialty billing and coding, we help you successfully create and submit clean claims.
Pediatric revenue runs through Medicaid and its managed care plans, VFC, CHIP, and EPSDT. It pays low under a strict payment system. Our experts know how to help you get paid.
If you bill a well-child visit at the wrong age or off the American Academy of Pediatrics' (AAP) Bright Futures schedule, you may face a claim denial. We carefully catch the claims that are billed the wrong way.
Your pediatric practice is assigned a dedicated account manager who knows about the payer intricacies and your claims submission process.
When you outsource pediatric billing services to MedCare MSO, you’re working with certified specialists who handle billing for 50+ specialties. Our team knows pediatric medicine inside and out where errors happen, what gets bundled, and how to catch problems before claims go out. We scrub every claim to make sure it’s clean before submission.
Our billers know which procedures get bundled, what’s covered under different plans, and how to code everything correctly the first time catching the mistakes that cause denials before a claim ever goes out. That means cleaner claims, faster payments, and less back-and-forth with insurance companies. When issues do come up, we handle them right away so your revenue doesn’t get stuck in limbo. Additionally, our AR recovery services ensure outstanding claims are diligently followed up on, reducing days in A/R and improving cash flow.
Pediatric medical billing is driven by patient age brackets determining the preventive-visit codes and vaccine administration has its own rules. Programs like VFC, CHIP (Children’s Health Insurance Program), and EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) add requirements that adult practices don’t face. It’s also high-volume at low per-claim value, so small recurring errors cost more than in other specialties.
Most pediatric billing companies charge a percentage of monthly collections, typically 3% to 7%. The exact rate depends on factors like claim volume and the scope of RCM services you need. After a free billing audit, we set the pricing structure with you.
Well-child visits use preventive-medicine codes: 99381–99385 for new patients and 99391–99395 for established patients, selected by age. The diagnosis is usually Z00.129 (routine child health exam with no abnormal findings), or Z00.121 when an abnormal finding is identified and addressed. The AAP’s Bright Futures schedule governs visit timing, and screenings performed during the visit can often be billed alongside it.
The core families are preventive-visit codes (99381–99395), office E/M codes (99202–99215, chosen by medical decision-making or time, for new and established patients), vaccine administration codes (90460–90461 and 90471–90474), developmental and behavioral screening codes (96110 and 96127), and newborn care codes (99460–99463).
The preventive checkup and the sick visit are billed separately. The sick visit gets its own problem-oriented E/M code with modifier 25 attached, showing it was significant, separately identifiable work not part of the checkup. Payers scrutinize these combinations, so documentation has to support both services.
Every vaccine claim has two pieces, one for the shot and the other for the administration. The product is reported with NDC. If physician counseling is involved, the administration bills 90460 for the first component and 90461 for each additional component. When there is no counseling involved, the 90471-90474 codes are used. These codes are based on the route, injectable versus oral or intranasal, and by first versus additional vaccine.
Yes. Each has its separate rules. VFC is a federal program that provides free vaccines. However, the administration stays billable, and EPSDT requires screenings and preventive services on schedule. This means billing it accurately is essential for clean claim submission. We manage all four programs.
We check eligibility and benefits before the visit, also check the secondary coverage as well. Before claim submission, we run claim scrubbing, age bracket checks, and program review. We run a root cause analysis after the claim denial so further denials can be avoided.
Yes. Normal newborn care uses the 99460–99463 family: for a baby in a hospital or birthing center, the first day is 99460, each subsequent day is 99462, and 99463 applies when the baby is admitted and discharged on the same date. (99461 covers initial care delivered outside a hospital or birthing center, such as a physician-attended home birth.) Babies who need NICU care follow separate neonatal critical- and intensive-care codes, and the work is often split between the attending and the hospital we map all of this during onboarding.
Our pediatric billing company handles everything: the vaccine component math, the program rules, the age-band coding, so your staff can stay with the kids, not the claims. Get a free billing review and see exactly where your revenue stands.
