Pediatric Billing and Coding ✔️ Everything you need to know!

Pediatricians have a lot on their plates. They need to provide excellent care to their young patients, but they also need to manage the administrative side of their practices. This can be a daunting task, especially when it comes to pediatric billing and coding.

Medical billing and coding is a complex and ever-changing field. There are a lot of rules and regulations that need to be followed, and it can be difficult to keep up with the latest changes. This is where a pediatric medical billing and coding company can help.

Before jumping to the importance and benefits of delegating the task of pediatric medical billing and coding to the Revenue Cycle Services Provider let’s check on some basics.

What is Pediatric Medical Billing and Coding?

Pediatric Medical Billing involves the management of billing and payment processes in pediatric practices. It encompasses handling payments from insurance companies as reimbursement and directly from patients as out-of-pocket fees. Essentially, it ensures that fees for pediatric services rendered are appropriately recorded and receivable.

Pediatric Coding is another crucial aspect, involving the accurate assignment of codes that correspond to specific medical procedures and diagnoses. These codes are essential for insurance companies to evaluate and approve claims. When the codes are assigned correctly, pediatric practices can maximize reimbursement by receiving payment from insurance providers.

Pediatric Billing and Coding Guidelines and Cheat Sheet

The preventive medicine codes are mostly grouped by the type and the age of the pediatric patient – New vs Established and are age-appropriate CPT codes.


99381 – < 1 year

99382 – > 1- 4 years

99383 – 5-11 years

99384 – 12-17 years

99385 – >17 years

99391 – < 1 year

99392 – 1-4 years

99393- 5-11 years

99394 – 12-17 years

99395 – >17 years



Services included under these codes include measurements (eg, length/ height, head circumference, weight, body mass index, blood pressure) and age- and gender-appropriate examination and history (initial or interval).

▶ Preventive medicine service codes are not time-based; therefore, time spent during the visit is not relevant in selecting the appropriate preventive medicine service code.

▶ If an illness or abnormality is discovered, or a preexisting problem is addressed, in the process of performing the preventive medicine service, and if the illness, abnormality, or problem is significant enough to require additional work to perform the components of a problem-oriented evaluation and management (E/M) service (ie, using medical decision making or time spent), the appropriate office or other outpatient service code (99202–99215) should be reported in addition to the preventive medicine service code. Append modifier 25 to the office or other outpatient service code (eg, 99392 and 99213 25).

▶ An insignificant or trivial illness, abnormality, or problem encountered in the process of performing the preventive medicine service should not be separately reported.

▶ The comprehensive nature of the preventive medicine service codes reflects an age- and gender-appropriate history and physical examination and is not synonymous with the comprehensive examination required for some other E/M codes (eg, 99204, 99205, 99215).

▶ Immunization products and administration and ancillary studies involving laboratory, radiology, or other procedures, or screening tests (eg, vision, developmental, hearing) identified with a specific CPT code, are reported, and paid for separately from the preventive medicine service code.



▶ Used to report services provided for the purpose of promoting health and preventing illness or injury.

▶ They are distinct from other E/M services that may be reported separately when performed. However, one exception is you cannot report counseling codes (99401–99404) in addition to preventive medicine service codes (99381–99385 and 99391–99395).

▶ Counseling will vary with age and address such issues as family dynamics, diet and exercise, sexual practices, injury prevention, dental health, and diagnostic or laboratory test results available at the time of the encounter.

▶ Codes are time-based, where the appropriate code is selected according to the approximate time spent providing the service. Codes may be reported when the midpoint for that time has passed. For example, once 8 minutes are documented, one may report 99401.

▶ Extent of counseling or risk factor reduction intervention must be documented in the patient chart to qualify the service based on time.

▶ Counseling or interventions are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.

▶ Cannot be reported with patients who have symptoms or established illness.

▶ For counseling individual patients with symptoms or established illness, report an office or other outpatient service code (99202– 99215) instead.

▶ The diagnosis codes reported for preventive counseling will vary depending on the reason for the encounter.

▶ Remember that the patient cannot have symptoms or established illness; therefore, the diagnosis codes reported cannot reflect symptoms or illnesses.

▶ Examples of some possible diagnosis codes include:

  • Z28.3 Underimmunized status (Code also reason patient is behind, eg, Z28.82 [caregiver refusal])
  • Z71.3 Dietary surveillance and counseling
  • Z71.82 Exercise counseling
  • Z71.84 Encounter for health counseling related to travel
  • Z71.85 Encounter for immunization safety counseling (Code also if vaccine is not carried out [eg, Z28.82])
  • Z71.89 Other specified counseling
  • Z71.9 Counseling, unspecified Behavior Change Interventions, Individual


  • Oral Health

CPT Code

  • 99188 Application of topical fluoride varnish by a physician or other qualified health care professional

ICD-10-CM Codes

  • 121 Routine child health exam with abnormal findings
  • 129 Routine child health exam without abnormal findings
  • 3 Encounter for prophylactic fluoride administration.
  • 841 Risk for dental caries, low
  • 842 Risk for dental caries, moderate
  • 843 Risk for dental caries, high
  • 849 Unspecified risk for dental caries

Pelvic Examination:

▶ Preventive medicine service codes (99381–99385 and 99391–99395) include a pelvic examination as part of the age- and gender-appropriate examination.

▶ If the patient is having a problem, the physician can report an office or other outpatient E/M service code (99212–99215) for the visit and attach modifier 25.

▶ Link the appropriate ICD-10-CM code for the well-child or well-adult examination with abnormal findings (Z00.121 or Z00.01) to the preventive medicine service code.

Why should you employ a professional pediatric medical billing and coding service provider?

  • It frees up time for pediatricians to focus on patient care. Pediatricians are already busy with their patients, so outsourcing their billing and coding can free up their time so they can spend more time with their patients.
  • It reduces the risk of errors. Medical billing and coding is a complex process, and there is a high risk of errors if it is not done correctly. Outsourcing to a B2B company can help to reduce the risk of errors.
  • It improves efficiency. A B2B company can help to improve the efficiency of the billing and coding process by using specialized software and processes.
  • It can save money. Outsourcing can save pediatricians money in the long run by reducing the need for in-house staff and by avoiding the cost of errors.

If you are a pediatrician, you should consider outsourcing your pediatric medical billing and coding services to a B2B company. This can help you to free up your time, reduce the risk of errors, improve efficiency, and save money.

Outsource Pediatric Medical billing and coding to QWay Healthcare:

QWay Healthcare brings to you expert-level professionals to simplify the medical coding and billing process for over 40+ specialties. You can schedule a free* demo call with us to optimize the revenue cycle operations of your organizations and streamline the process with an insight-driven approach. Write to Our Helpdesk.

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