Pediatric Billing Services Built Around EPSDT, Vaccine Coding, and Same-Day Well-Sick Visits
ClaraRCM handles age-banded preventive visit coding, vaccine administration billing, EPSDT compliance, and modifier 25 documentation for pediatric practices across all 50 states, so well-child visits and same-day sick visits both get paid correctly.
U.S.-based billing and coding team. No offshore operations.
Get a Free Pediatric Billing Audit
See exactly where vaccine coding and modifier 25 errors are costing your practice on same-day well and sick visits.
What Is Pediatric Billing, and Why Do Well-Child Visits Get Denied?
Pediatric billing is the process of coding and submitting claims for age-banded preventive visits (CPT 99381 to 99395), vaccine products and administration, and same-day sick visits, while meeting Medicaid's Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements for patients under age 21.
Pediatric billing carries a coding structure unlike almost any other specialty. Preventive visit codes are selected purely by the child's age and new-versus-established status, not by time or medical decision making. Vaccines require two codes on every line, a product code and a separate administration code, and the administration code changes based on whether counseling was documented and whether the patient is under 19. Layer on Medicaid's EPSDT mandate, which entitles every Medicaid-enrolled child under 21 to comprehensive preventive services, and the margin for coding error narrows fast.
Our team builds age-verification, vaccine component counting, and modifier 25 documentation checks directly into the coding workflow so well-child and same-day sick visit claims go out clean the first time.
| Problem | ClaraRCM Fix |
|---|---|
| Wrong age-band preventive code selected for date of service | Automated age verification against the patient's exact date of birth on every claim |
| Sick visit denied because modifier 25 is missing | Coders confirm distinct, separately documented well and sick notes before submission |
| Vaccine administration code mismatched to component count | Component-by-component review of 90460/90461 units against the vaccine given |
| New patient billed as established, or the reverse | Three-year same-specialty, same-group visit history checked before code selection |
| EPSDT screening component missing from documentation | Visit checklist cross-referenced against the Bright Futures/AAP Periodicity Schedule |
Same-Day Well-Sick Visit and Vaccine Coding Revenue Calculator
Missing modifier 25 on a same-day sick visit, or under-billing vaccine administration components, are two of the most common preventable revenue losses in pediatric billing. Estimate what these gaps could be costing your practice.
This estimate is directional and depends on your actual payer contracts, vaccine mix, and documentation. It is not a substitute for a claims audit.
Get This Analysis Run on Your Actual Claims
Send us your calculator inputs and we will run a real coding and documentation review against a sample of your recent well-child visits.
Pediatric CPT Codes: 2026 Reference Table
Updated for 2026 CPT and CMS/Medicaid policy. Vaccine and preventive visit reimbursement is set by each state Medicaid program and by individual commercial payer contracts rather than a single national rate. Always verify current amounts against your state Medicaid fee schedule or payer contract before billing.
| Code | Description | Reimbursement Basis | Coverage Notes |
|---|---|---|---|
| 99381 to 99384 | New patient preventive medicine visit, by age band (under 1, 1 to 4, 5 to 11, 12 to 17) | Set by state Medicaid fee schedule or commercial contract | Selected by age and new-patient status only, not time or MDM |
| 99391 to 99394 | Established patient preventive medicine visit, by age band | Set by state Medicaid fee schedule or commercial contract | Use when the child has been seen by the same specialty/group within 3 years |
| 90460 | Immunization administration through age 18, any route, with counseling; first component | Example: Iowa Medicaid VFC administration cap of $19.68 per the state's official rate notice | Reimbursement varies by state Medicaid program and payer |
| 90461 | Each additional vaccine or toxoid component, with counseling | Add-on to 90460; billed per component | Cannot be billed alone; must accompany 90460 |
| 90471 to 90474 | Immunization administration without counseling, or for patients 19 and older | Set by state Medicaid fee schedule or commercial contract | Not used for patients under 19 when counseling was documented |
| 90482 to 90484 | Immunization counseling with no vaccine given, 3 to 10, 11 to 20, and over 20 minutes | Medicare assigns status indicator "I" (not separately reimbursed by Medicare) | New CPT codes effective January 1, 2026; check individual commercial and Medicaid payer policies |
| 96110 | Developmental screening, with scoring and documentation | Set by state Medicaid fee schedule or commercial contract | Billed in addition to a well-child E/M at the same visit |
| Modifier 25 | Significant, separately identifiable E/M on the same day as a preventive visit | N/A (modifier) | Required when a sick complaint is addressed at the same encounter as a well-child visit |
Sources: Medicaid.gov EPSDT benefit page; AAP/Bright Futures Periodicity Schedule (published in Pediatrics, American Academy of Pediatrics); CPT code descriptors as published by the American Medical Association; Iowa Medicaid Informational Letter on VFC administration code rates.
How ClaraRCM Handles Your Pediatric Billing
Eligibility & Age Verification
We verify Medicaid or commercial eligibility at every visit, since pediatric coverage changes frequently, and confirm the exact age band for preventive coding.
Certified Coding
Certified coders select the correct preventive code, count vaccine components for 90460/90461, and apply modifier 25 only when documentation supports a distinct sick visit.
Claim Scrubbing & Submission
Every claim is scrubbed against payer-specific EPSDT and vaccine bundling rules before electronic submission.
Denial Management & Follow-Up
Denied or bundled claims are worked and appealed quickly, with root-cause tracking so the same modifier or age-band error does not repeat.
Why Pediatric Practices Choose ClaraRCM
EPSDT-Aligned Coding
We cross-check every well-child visit against the Bright Futures/AAP Periodicity Schedule and your state's EPSDT requirements.
97% Clean Claim Rate
Age-band verification and vaccine component checks keep first-pass acceptance high on high-volume pediatric claim streams.
14-Day Average Reimbursement
Clean claims and disciplined follow-up mean pediatric practices get paid faster, even with a heavy Medicaid payer mix.
U.S.-Based Certified Coders
Our entire coding and billing team operates in the United States. No offshore handoffs on vaccine and modifier 25 review.
All 50 States, Every Payer Mix
We currently support 500-plus providers nationwide, including pediatric practices with high-Medicaid, high-CHIP payer mixes.
35% Average AR Reduction
Proactive denial workflows and eligibility re-checks bring accounts receivable down instead of letting Medicaid churn stack up.
Before ClaraRCM vs. After ClaraRCM
| Metric | Before | After ClaraRCM |
|---|---|---|
| Clean claim rate | Below industry benchmark, frequent modifier 25 and vaccine denials | 97% clean claim rate |
| Collection ratio | Inconsistent, especially on same-day well-sick visits | 98.5% collection ratio |
| Accounts receivable | Aging past 60 to 90 days on Medicaid eligibility churn | 35% average AR reduction |
| Days to reimbursement | 30-plus days on reworked claims | 14 days average |
| Vaccine component billing | Manual counting, inconsistent unit accuracy | Component-by-component review before every submission |
Figures reflect ClaraRCM's aggregate client performance metrics across specialties. Individual results vary by payer mix and starting baseline.
Pediatric Billing vs. Family Medicine Billing: What's Actually Different
Pediatric billing is often assumed to be a smaller version of family medicine billing, but the coding structure, coverage rules, and payer mix are meaningfully different.
| Factor | Pediatric | Family Medicine |
|---|---|---|
| Preventive visit codes | Age-banded 99381 to 99395, selected by age alone | Adult preventive codes 99385 to 99397, also age-banded but fewer pediatric-specific rules |
| Vaccine billing structure | Product code plus a separate, component-counted administration code (90460/90461) | Vaccine billing exists but at lower volume and complexity per visit |
| Governing coverage mandate | Medicaid EPSDT benefit for patients under 21 | Standard Medicaid/Medicare adult coverage rules, no EPSDT mandate |
| Typical payer mix | Often Medicaid- and CHIP-heavy, with frequent eligibility changes | Mixed Medicare, Medicaid, and commercial, generally more stable eligibility |
| Same-day visit pattern | Frequent well-plus-sick visits requiring modifier 25 and split documentation | Less frequent same-day preventive-plus-acute combination |
Billing Services for Related Specialties
Related ClaraRCM Services
FQHC & Rural Health Clinic Billing
For pediatric practices operating within or alongside a federally qualified health center.
Learn more →Denial Management & AR Recovery
Root-cause denial resolution for modifier 25 and vaccine bundling denials.
Learn more →Telehealth & Virtual Care Billing
For pediatric practices offering virtual sick visits and immunization counseling.
Learn more →Mental Health & Behavioral Health Billing
For pediatric practices integrating behavioral health screening and referral services.
Learn more →Pediatric Billing: Frequently Asked Questions
EPSDT, the Early and Periodic Screening, Diagnostic and Treatment benefit, is a federal Medicaid mandate that entitles children under 21 to comprehensive preventive services. Per Medicaid.gov, states must furnish any Medicaid-coverable, medically necessary service to correct or ameliorate a condition found during screening, even if that service is not otherwise covered for adults in that state.
Yes, when the provider addresses a significant, separately identifiable problem beyond routine preventive care. The sick-visit E/M code must carry modifier 25, and the chart must contain two distinct notes, one for the preventive service and one for the problem-oriented service, to support both claims on audit.
CPT 90460 is used for patients through age 18 when a physician or qualified health professional documents counseling, billed per vaccine component. CPT 90471 to 90474 apply when no counseling was documented, or when the patient is 19 or older, and are billed per vaccine rather than per component.
Unlike problem-oriented E/M codes, preventive medicine codes 99381 to 99395 are selected based solely on the patient's exact age on the date of service and whether they are a new or established patient, not on time spent or medical decision making complexity.
A patient is established if any physician of the same specialty in the same group has provided a face-to-face service within the past three years, regardless of the reason for that prior visit. A sick visit four months earlier makes a child established for a later well-child visit, even at a new practice location within the same group.
Effective January 1, 2026, CPT added codes 90482 through 90484 to report immunization counseling on a date when no vaccine is actually administered, based on time spent (3 to 10, 11 to 20, or over 20 minutes). Medicare has assigned these a non-payable status, so commercial and state Medicaid payer policies should be verified before billing.
Under the VFC program, eligible children receive vaccine products at no cost to the practice, so the vaccine product code is typically billed at $0. Practices bill separately for the administration service using 90460/90461 or 90471 through 90474, and administration fee amounts are set individually by each state Medicaid program.
States set their own periodicity schedule for well-child visits under EPSDT, and most states adopt the Bright Futures/AAP Periodicity Schedule. Services delivered more frequently than the schedule are still covered when medically necessary for an individual child, per federal EPSDT rules.
CPT 96110 requires documentation of the specific screening tool used, the score obtained, and the clinician's interpretation of the result. It is billed in addition to the well-child E/M code at the same visit and does not require a modifier in most payer policies.
The most common cause is a mismatch between the number of 90461 units billed and the actual number of additional vaccine components administered, or billing 90471 to 90474 for a patient under 19 when counseling was actually documented, which should have triggered 90460/90461 instead.
Pediatric billing uses age-banded preventive codes tied to the EPSDT mandate, a component-based vaccine administration structure, and a payer mix that is frequently Medicaid- and CHIP-heavy. Family medicine billing covers a broader age range with fewer age-specific coding rules and generally more stable patient eligibility.
For most small pediatric practices, outsourcing removes the burden of tracking age-banded coding, vaccine component counting, and state-specific EPSDT requirements in-house, while typically improving clean claim rates given how frequently Medicaid eligibility changes for pediatric patients.