Specialties › Pediatric Billing
Pediatric billing is unlike any other specialty. Patients grow through 5 distinct billing age-bands — each with different well-child codes, different vaccine schedules, different EPSDT screening requirements, and different developmental screening add-ons. Add Medicaid complexity (30–70% payer mix in most pediatric practices), vaccine multi-component billing, and sick-visit same-day rules — and you have a specialty where generalist billing teams routinely miss 30–45% of available revenue.
The average pediatric practice loses $180,000–$520,000 annually to missed vaccine administration codes, under-coded developmental screenings, wrong well-child CPT codes for the patient's age, and unbilled EPSDT screening services on Medicaid encounters. A ParaMed pediatric billing audit finds every gap — at no cost.
Established · 18-month WCV · DTaP + MMR + Varicella + Hep A · Developmental screening · Medicaid
Established 1–4 yr age band · Comprehensive preventive E&M
Counseling-based admin code × 4 vaccines with counseling each
DTaP 90700 + MMR 90707 + Varicella 90716 + HepA 90633
M-CHAT or ASQ administered + scored at 18-month visit
EPSDT-required lead test interpretation at 12–24 months
Revenue Recovered: Prior billing used 90461 instead of 90460 for all vaccines — losing $10/vaccine × 4 = $40 per well visit. At 60 WCV/month this is $2,400 monthly from a single administration code error.
Newborn billing occurs in two distinct phases: the hospital newborn care episode (days 1–28) and the first outpatient office visit after discharge. Hospital newborn care is billed with newborn-specific E&M codes (99460–99463) that are separate from and in addition to any circumcision, hearing screening, or PKU testing performed during the admission. Most general billing teams miss the day-2 and subsequent-day newborn visit codes, billing only the admission-day code.
| CPT | Description | Rate |
|---|---|---|
| 99460 | Initial Normal Newborn — Day 1Admit | $138 |
| 99462 | Subsequent Newborn — Each Add'l DayDaily | $94 |
| 99463 | Admit + Discharge Same DaySame-Day | $162 |
| 99381 | New Pt Preventive — Under 1 YearFirst Visit | $198 |
| 92558 | Newborn Hearing ScreeningScreen | $48 |
| 54150 | Circumcision — ClampProcedure | $218 |
| 99391 | Established Preventive — Under 1 yrWCV | $172 |
Infants receive the highest concentration of vaccines of any age group — the immunization schedule from 2 months through 12 months includes up to 8 separate vaccines at a single visit. Each vaccine requires two billing codes: the vaccine product code (e.g., 90700 for DTaP) AND the vaccine administration code (90460 for counseling-based admin).
| CPT | Description | Rate |
|---|---|---|
| 99391 | Well Visit — Established, Under 1 yrWCV | $172 |
| 99381 | Well Visit — New Patient, Under 1 yrNew | $198 |
| 90460 | Vaccine Admin with Counseling (1st)Admin | $32 |
| 90461 | Vaccine Admin Add-On per ComponentAdd-On | $9 |
| 90700 | DTaP Vaccine ProductVaccine | $28 |
| 90680 | Rotavirus Vaccine (2-dose or 3-dose)Vaccine | $84 |
| 96110 | Developmental Screening (M-CHAT)Screen | $38 |
The 12-month through 4-year age range is where EPSDT developmental and autism screening requirements generate the most separately billable services in pediatrics. The M-CHAT (Modified Checklist for Autism in Toddlers) at 18 and 24 months, ASQ-3 developmental screening, and lead blood level testing at 12 and 24 months are all reimbursable services routinely not billed or folded into the well-visit code.
| CPT | Description | Rate |
|---|---|---|
| 99392 | Well Visit — Established, 1–4 YearsWCV | $162 |
| 99382 | Well Visit — New Patient, 1–4 YearsNew | $186 |
| 96110 | Developmental/Autism Screening (M-CHAT)Screen | $38 |
| 83655 | Lead Blood Level TestLab | $28 |
| 99213 | Sick Visit Same-Day (Mod -25)Sick | $105 |
| 90460 | Vaccine Admin with CounselingAdmin | $32 |
| 90707 | MMR Vaccine ProductVaccine | $64 |
| 90716 | Varicella Vaccine ProductVaccine | $98 |
School-age well visits (99393 for 5–11 years established, 99383 new patient) have lower vaccine volume than the infant/toddler years but generate revenue through annual preventive screenings, ADHD initial evaluations, and behavioral health integration coding. ADHD diagnosis and coding generates a significant secondary revenue stream — the comprehensive ADHD evaluation (96127 × multiple instruments, 99213 office E&M) is often significantly underbilled.
| CPT | Description | Rate |
|---|---|---|
| 99393 | Well Visit — Established, 5–11 YearsWCV | $178 |
| 99383 | Well Visit — New Patient, 5–11 YearsNew | $204 |
| 99173 | Vision ScreeningScreen | $18 |
| 99172 | Hearing ScreeningScreen | $24 |
| 96127 | Behavior Assessment (Vanderbilt/Conners)Screen | $29 |
| 90658 | Flu Vaccine 3yr+ (IIV, Multi-dose)Flu | $22 |
| 90471 | Flu Admin Code (non-counseling)Admin | $28 |
Adolescent billing (99394 established, 99384 new patient) introduces unique complexity: confidential services that may not be billable to the parent's insurance under state minor consent laws, depression and anxiety screening requirements (PHQ-A, CRAFFT), HPV vaccine series billing, and sports physical documentation standards. The PHQ-A depression screen at every adolescent well visit is separately billable (96127) — most practices don't bill it separately.
| CPT | Description | Rate |
|---|---|---|
| 99394 | Well Visit — Established, 12–17 YearsWCV | $192 |
| 99384 | Well Visit — New Patient, 12–17 YearsNew | $218 |
| 96127 | PHQ-A Depression ScreeningScreen | $29 |
| 96127 | CRAFFT Substance Use ScreeningScreen | $29 |
| 90651 | HPV 9-Valent VaccineVaccine | $184 |
| 90460 | Vaccine Admin with CounselingAdmin | $32 |
| 99401 | Preventive Counseling 15 minCounsel | $58 |
Every administered vaccine requires both a product code AND an administration code — but 90460 vs. 90461 selection errors, missed component add-ons, and failure to capture all vaccines per visit result in substantial per-encounter vaccine revenue loss that compounds across thousands of annual visits.
M-CHAT, ASQ-3, PHQ-A, Vanderbilt, CRAFFT — these standardized screening tools are already being administered at well visits but 72% of pediatric practices don't bill 96110 or 96127 separately, assuming they're included in the well-visit code. They are not.
When a child presents for a well visit but also has an acute complaint requiring separate evaluation and management, the sick visit is separately billable with modifier -25 on the E&M code. Most practices either don't bill the same-day sick visit at all, or document it without the -25 modifier causing denial.
Large pediatric practices (5+ physicians) with high Medicaid volume, active EPSDT obligations, high vaccine throughput, and comprehensive developmental screening programs face the widest billing gaps — because each category of missed revenue compounds at higher volume.
In pediatric billing, the correct CPT code for the same type of service — a preventive well visit — changes with every birthday milestone. A 11-month-old and a 13-month-old have different well-visit codes, different vaccine schedules, different screening requirements, and potentially different EPSDT obligations. Generalist billing teams that don't know pediatric age-band billing miss these distinctions on every encounter.
Preventive well-child visits use age-specific CPT codes: 99381–99385 for new patients and 99391–99395 for established patients, each covering a specific age range. Using 99392 (1–4 years) for a 4-year-11-month-old patient whose age actually maps to 99393 (5–11 years) triggers an automatic denial from payers that validate age against the billed CPT code.
Every administered vaccine generates two separate billing codes: (1) the vaccine product code (e.g., 90700 for DTaP) and (2) the vaccine administration code (90460 with counseling, 90461 add-on, or 90471 without counseling). Missing either code loses that component of revenue. For a visit with 6 vaccines, 12 separate codes should be on the claim — and many practices submit 6.
EPSDT requires comprehensive screening at every Medicaid well-child visit — developmental, vision, hearing, dental, lead (12–24 months), autism (18 and 24 months), and behavioral health screenings. Each component that is administered and documented is separately billable. Practices with 40–70% Medicaid panels who aren't billing EPSDT screening codes are forfeiting $40–$120 per Medicaid well visit.
When a child presents for their scheduled well-child visit but the parent also raises an acute concern that requires a separately documented evaluation — the sick visit is billable with modifier -25 on the E&M code in addition to the well-visit code. When it is billed without -25, the payer bundles both services and pays only the well-visit rate, losing the sick-visit revenue.
Pediatric practices carry the highest Medicaid payer mix of any outpatient specialty — often 40–70% of their patient panel. Medicaid rules for pediatrics differ from commercial insurance: EPSDT screening requirements, vaccine billing through VFC (Vaccines for Children) vs. private purchase, specific prior authorization requirements for developmental therapy referrals, and state-specific parity rules add complexity that commercial-only billing teams are not equipped to manage.
A busy pediatric practice administers 800–2,000+ vaccines monthly. Each vaccine generates two billing codes. The difference between correct vaccine billing and the most common errors — wrong admin code, missing product code, VFC vs. private purchase routing confusion — translates to $18–$40 per vaccine in lost revenue.
The preventive E&M code for the age-appropriate well visit — covers the comprehensive history, exam, counseling, and anticipatory guidance component. Must match patient's age at date of service exactly.
99391–99395$162–$224One product code per vaccine administered — DTaP (90700), MMR (90707), Varicella (90716), Hepatitis A (90633), Hepatitis B (90744), etc. Combination vaccines use the combination product code. One code per distinct vaccine product.
90xxx × N vaccines$18–$184/vaccine90460 (with physician counseling — each vaccine when counseled). The counseling-based code applies when the physician or QHP personally counsels the patient/parent at the time of each vaccine. Not a one-and-done per visit — per vaccine.
90460 × N vaccines$32/each (all with counseling)The most confusing billing scenario in pediatrics is also the most common: a child scheduled for a well visit presents with an acute complaint. Understanding when a same-day sick visit is separately billable, how to document it correctly, and which modifier to apply determines whether a practice collects $105–$218 more per encounter or forfeits the sick visit revenue entirely.
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Well-child visit for a child under 1 year who has previously been seen at this practice. Covers comprehensive preventive history, examination, immunization review, and parent/guardian counseling. Required at 1, 2, 4, 6, 9, and 12-month visits.
First well-child visit for a child under 1 year not previously seen at this practice — including transfer of care from another pediatric practice, or a newly established patient.
Child age 3 years comes for 3-year well visit. Parent mentions ear pain for 2 days. Physician examines ear, documents otitis media, prescribes amoxicillin. Practice bills: 99392 (well visit) only. Revenue lost: $105.
Same scenario. Practice bills: 99392 (well visit, $162) + 99213-25 (separately documented E&M for otitis media with modifier -25, $105). Both services separately documented, both submitted. Payer pays both.
EPSDT requires comprehensive screening at every Medicaid well-child visit — covering developmental, sensory, dental, lead, behavioral health, and nutritional assessments. Each administered and documented screening is separately billable. Practices with 40%+ Medicaid payer mix who aren't billing EPSDT screening codes are forfeiting tens of thousands annually.
Administration of a standardized developmental screening tool (ASQ-3, Denver II, PEDS) — separately billable from the well-visit code. Required at all Medicaid well visits from birth through 36 months. One of the most consistently missed billing codes in pediatrics.
Blood lead level testing — required by Medicaid EPSDT at 12 and 24 months, and for children 25–72 months at high risk. The venipuncture/capillary collection, lead level test, and physician interpretation are each separately billable components.
In-office vision screening (99173) and hearing screening (99172) — both separately billable at each well visit beginning at age 3 years for vision and birth for hearing. The most commonly performed-but-not-billed services in pediatric well-child care.
PHQ-A (adolescent depression), CRAFFT (substance use), Vanderbilt (ADHD), or other standardized behavioral assessment instruments — each separately billable per administration. Applicable across school-age and adolescent visits.
Medicaid payer mix in pediatrics is unlike any other specialty. EPSDT screening requirements, VFC vaccine billing rules (admin code only — no product code for VFC doses), state-specific behavioral health billing variations, and Medicaid-specific prior authorization requirements create a billing environment that commercial-trained billing teams consistently mismanage — generating denials, underpayments, and compliance risk.
Medicaid in pediatrics is not simply a different fee schedule. It has fundamentally different rules: EPSDT screening requirements with billing codes, VFC vaccine program routing that changes what can be billed, prior authorization requirements for behavioral health referrals, and state-specific supplemental billing rules that vary by state plan. A billing team trained only on commercial payers will create compliance violations on Medicaid encounters — not just revenue loss.
VFC provides free vaccines to Medicaid-eligible children (and certain other uninsured/underinsured children) through the federal Vaccines for Children program. Practices enrolled in VFC receive vaccines at no cost — and therefore can only bill for the administration of VFC vaccines, not the product cost. The billing error: submitting a vaccine product code (90700, 90707, etc.) for a VFC dose and collecting payment for a vaccine that was received free. This creates an overpayment and a Medicaid compliance issue.
Patient is commercially insured or self-pay. Vaccine was purchased by the practice (not VFC). Bill: vaccine product code (e.g., 90700 DTaP = $28) PLUS administration code (90460 = $32). Both codes submitted on same claim line or separate lines.
Product + AdminPatient is Medicaid-eligible (or CHIP, uninsured, underinsured per VFC eligibility). Vaccine received through VFC at no cost. Bill: administration code ONLY (90460 with counseling = $32). Do NOT submit product code — this is a compliance violation.
Admin Only — No ProductVFC eligibility must be screened at every vaccine visit — not assumed from payer type. A commercially insured patient may still be VFC-eligible if underinsured (insurance doesn't cover vaccines). Screening documentation required for VFC compliance audits.
Document Every VisitVFC and privately purchased vaccines must be stored separately and tracked separately. Administering a VFC dose to a private-pay patient and billing the product code = misappropriation of federal VFC inventory. ParaMed helps establish correct inventory routing protocols.
Inventory ComplianceMedicaid well-child visit claims must include the EPSDT diagnosis code — Z00.121 (under 28 days) or Z00.129 (other age, routine well visit). Missing this code causes the claim to process as a non-preventive visit and may trigger underpayment or denial on some Medicaid managed care plans.
Required Dx CodeWhen a pediatrician refers a patient for behavioral health therapy (ABA, speech, occupational therapy), many Medicaid managed care plans require a prior authorization from the referring pediatrician. Without PA, therapy claims deny and families face unexpected bills.
PA ManagementPediatric sick visits have specific billing rules for each diagnosis category — from the correct E&M level selection to the separately billable in-office procedures (rapid strep test, nebulizer treatment, laceration repair) that most practices either don't bill or fold into the E&M code.
The most common pediatric diagnosis — ear infection. Billing correctly requires the appropriate E&M level (usually 99213 for straightforward MDM, 99214 for complex or bilateral AOM) plus any in-office audiometry if performed.
URI with in-office rapid strep test. The rapid strep test (86403) and specimen collection (87880 if with interpretation) are separately billable procedure codes beyond the E&M — but most practices fold the test into the office visit with no additional charge.
ADHD initial evaluation generates significantly higher revenue when billed correctly. Vanderbilt assessment instruments (96127 × 2), behavioral assessment interpretation (96130), and the E&M visit all bill separately. The interpretation code (96130) adds $144 to the evaluation billing.
Acute asthma exacerbation with in-office nebulizer treatment — the nebulizer treatment (94640) and extended nebulizer observation time (94644/94645 for subsequent treatments) are separately billable beyond the E&M. Many practices bill only the E&M for acute asthma visits.
Confirmed strep pharyngitis with positive rapid strep and throat culture — both the rapid antigen test and the culture send-out are separately billable services. When the culture is sent to an in-house lab, the culture code (87081) is billable by the practice.
Pediatric rash evaluation generates higher MDM E&M when the differential includes conditions requiring diagnostic decision-making. When the evaluation includes prescription corticosteroids with monitoring plan, or specialist referral decision — MDM supports 99213–99214 range with complexity documentation.
Every one of these denial patterns is systematic — affecting dozens or hundreds of encounters monthly, compounding silently across the full patient volume. None of them require clinical changes. All of them require billing workflow corrections.
90460 (vaccine administration with physician counseling) is the higher-value administration code — applying when the physician or QHP counsels about each vaccine at the time of administration. Many billing teams use 90460 × 1 + 90461 × remaining vaccines for every encounter — when the physician actually counsels about all vaccines, generating 90460 × N. For 4 vaccines: 90460 × 4 = $128 vs. 90460 × 1 + 90461 × 3 = $59. A $69 difference per 4-vaccine visit × 80 vaccine encounters/month × 12 = $66,240 annually.
Standardized developmental and behavioral health screening tools — M-CHAT, ASQ-3, PHQ-A, Vanderbilt, CRAFFT — administered at well visits are separately billable with CPT 96110 (developmental screen, $38) or 96127 (behavioral assessment, $29). These codes are not bundled into the well-visit E&M. 72% of pediatric practices don't bill 96110 or 96127 at all, assuming they're included. For a practice administering developmental screens at 120 well visits monthly, missing 96110 × 120 = $4,560 monthly, $54,720 annually.
When a separately documented E&M is billed on the same day as a well-child visit — for an acute complaint evaluated independently — the E&M must carry modifier -25 (significant, separately identifiable E&M service on same day as a procedure/preventive service). Without modifier -25, the payer automatically bundles the E&M into the well-visit code. This is one of the most consistent, preventable denials in pediatric billing — occurring on every same-day sick + well encounter submitted without -25.
Well-child visit codes are age-specific — 99391 (under 1 year), 99392 (1–4 years), 99393 (5–11 years), 99394 (12–17 years) for established patients. Payers that validate the billed CPT code against the patient's date of birth at date of service will auto-deny a claim where the age doesn't match the code range. Common error: a child turning 5 whose practice hasn't updated the code from 99392 to 99393. Hundreds of annual visits affected in high-volume practices with manual age-code selection.
Billing a vaccine product code (e.g., 90700 DTaP, $28) for a vaccine dose that was received through the VFC program (at no cost to the practice) is a Medicaid billing compliance violation — it represents billing for a product that the practice did not pay for. Beyond the immediate financial risk (Medicaid will demand recoupment), this creates federal fraud and abuse exposure under the False Claims Act. This error is surprisingly common in practices where the billing team doesn't know which vaccine doses are from VFC inventory vs. privately purchased stock.
In-office procedures performed during a sick visit — rapid strep test (86403 + 87880), nebulizer treatment (94640 + 94645), in-office audiometry (92552), in-office vision testing (99173) — are separately billable procedure codes that generate additional revenue beyond the E&M. Practices where the front desk or MA adds these as included in the visit and doesn't flag them for separate billing lose $22–$124 per encounter where these procedures were performed but not coded.
Pediatric chronic conditions — ADHD, asthma, autism, obesity, diabetes — generate ongoing monthly visit billing that is systematically undercoded. ADHD medication management visits billed as 99212 instead of 99213. Asthma action plan documentation that supports 99214 but gets billed as 99213. Chronic care management codes never applied.
Each standardized behavioral assessment instrument at an ADHD visit is separately billable. Parent Vanderbilt + Teacher Vanderbilt = 96127 × 2 at the initial evaluation and at follow-up visits where scales are re-administered.
$29 each administrationWhen the physician interprets and integrates behavioral assessment results (Vanderbilt, Conners, BRIEF), the interpretation code generates $144 per evaluation in addition to the E&M. Most pediatric practices bill only the E&M for ADHD evaluations — missing the interpretation code entirely.
$144 per evaluationADHD medication management visits reviewing stimulant response, side effects (appetite, sleep, growth), behavioral data, academic performance, and considering dosing adjustments consistently support 99214 (moderate MDM) — not 99213 which most practices default to.
$148 vs. $105 for 99213When a pediatric practice performs in-office spirometry for asthma diagnosis or monitoring, spirometry code 94010 ($88) is separately billable beyond the E&M visit. Practices with spirometers commonly perform this test but bill it as part of the E&M rather than as a separately coded procedure.
$88 separately billedInitial in-office nebulizer treatment for acute asthma exacerbation — a separately billable procedure code from the E&M visit. 94644/94645 apply to subsequent treatments in the same session.
$48 first treatmentAsthma control assessments reviewing controller medication adherence, rescue inhaler use frequency, trigger avoidance, asthma action plan update, and prescription management consistently support 99214 (moderate MDM) — not 99213.
$148 (99214 MDM supported)Obesity-related billing requires both the obesity diagnosis (E66.x) AND the BMI percentile code (Z68.xx for pediatric BMI coding — Z68.51–Z68.54 for pediatric BMI percentile ranges). Missing the BMI code causes obesity-related service claims to reject as unsupported.
Diagnosis accuracy — requiredWhen a physician provides face-to-face counseling on obesity, nutrition, or physical activity beyond the standard well-visit counseling — this generates preventive counseling code 99401 (15 min) or 99402 (30 min) as a separately billable service.
$58 (15 min) / $84 (30 min)When the pediatric practice employs a registered dietitian or is billing for dietitian-provided nutrition counseling, S9470 or Medical Nutrition Therapy codes (97802–97804) may apply depending on the payer. Commercial insurance coverage varies significantly by plan.
Variable by payerFor pediatric patients with two or more chronic conditions (ADHD + asthma, autism + epilepsy, etc.) expected to last 12+ months, CCM generates $62/month per patient for the care coordination activities performed between office visits — including medication review, care plan updates, and care coordination calls.
$62 per patient per month99439 is the add-on code for each additional 20 minutes of CCM time beyond the first 20 minutes in a calendar month. Complex pediatric patients (severe autism + epilepsy + behavioral health) often generate 40–60 minutes of monthly care coordination that qualifies for 99490 + 99439 × 1–2.
$48 each additional 20 minWhen the physician personally provides the CCM services (rather than clinical staff), 99491 applies at a higher reimbursement rate ($84/month). For a practice managing 50 CCM patients monthly, the physician-performed distinction generates $1,100 more monthly.
$84 per patient per monthAge-specific WCV billing, complete vaccine product and admin code capture, EPSDT screening code billing, VFC compliance management, Medicaid payer expertise, and chronic condition code optimization — all in one pediatric billing partnership.
Every well-child visit claim validated against patient's date of birth at date of service — correct age-band CPT code applied on every encounter, preventing age-mismatch denials across all payers.
All vaccine billing across VFC and private purchase — correct product + admin code combination for private pay, admin-only for VFC doses, 90460 vs. 90461 counseling-based selection, and combination vaccine product code routing.
Every EPSDT screening service documented in the chart matched to its billable code — 96110 for developmental screens, 96127 for behavioral assessments, 99173 vision, 99172 hearing, 83655 lead — applied at every qualifying Medicaid well visit.
Full Medicaid billing compliance for pediatric practices — EPSDT diagnosis codes, VFC routing rules, prior authorization management for behavioral referrals, and state-specific Medicaid billing rule variations managed for your state plan.
CCM program identification and enrollment for qualifying pediatric patients with 2+ chronic conditions — monthly CCM billing (99490/99491), documentation workflow, and patient care plan management to sustain ongoing monthly revenue.
Same-day sick + well billing with -25 modifier applied on every qualifying encounter, plus in-office procedure billing for rapid strep, nebulizer treatments, audiometry, and other separately coded in-office services performed during sick visits.
A 5-step workflow purpose-built for pediatric complexity — age validation, vaccine billing audit, screening code capture, Medicaid compliance check, and clean claim submission on every encounter.
Patient age verified against WCV CPT code on every claim — age-band mismatch flagged and corrected before submission to prevent payer denial.
All vaccine encounters reviewed: VFC vs. private routing, correct product codes, 90460 counseling vs. 90461 add-on selection, and quantity verified against chart documentation.
Chart review for all administered screening instruments — 96110, 96127, 99173, 99172, and 83655 added to every claim where documentation supports separate billing.
Medicaid claims reviewed for EPSDT diagnosis codes, VFC billing compliance, -25 modifier application, and prior auth verification before submission.
98.1% first-pass acceptance rate. Claims submitted within 96 hours, tracked through payment, and analyzed monthly for denial pattern trends.
The revenue recovered by ParaMed in pediatric practices doesn't come from billing more visits — it comes from billing the visits that are already happening, correctly and completely, for the first time.
"We had 3 physicians seeing 45 well-child visits per day combined. Our billing team was billing 90460 × 1 + 90461 for everything — we had no idea 90461 was the wrong code for our physician-counseling encounters. ParaMed's audit showed we were under-billing $74 per vaccine encounter on average, across 8,000+ vaccine encounters per year. The math was staggering — we were leaving $592,000 on the table annually from a single administration code selection error. ParaMed corrected it and our revenue changed literally overnight."
"60% of our patients are Medicaid. We were administering M-CHAT screens at every 18 and 24-month well visit and PHQ-A at every adolescent visit — but never billing 96110 or 96127 separately because our biller said they were included in the well-visit code. They're not included. ParaMed showed us we were doing 220 screening instruments monthly and billing for zero of them. That's 220 × $38 or $29 = $7,480/month and $89,760/year in screening code revenue that we were performing but never capturing."
"I manage 90 ADHD patients for ongoing medication management. My previous billing submitted every ADHD return visit as 99213. ParaMed reviewed the charts and showed me that the medication management documentation — side effect review, growth monitoring, behavioral scale re-administration, school coordination notes, dosing adjustments — consistently supported 99214. At $43 additional per visit × 90 patients × roughly 4 visits per year = $15,480 annually from code level selection on a chronic condition I'm already managing. Now they also bill 96127 × 2 at the visits where we re-administer Vanderbilt. Game changer."
The revenue gaps in pediatric billing don't come from seeing more patients. They come from billing the patients you're already seeing — completely. Vaccine admin code selection errors, unbilled developmental screenings, missed same-day sick visit modifiers, and wrong age-band codes are costing your practice every single day. A ParaMed audit finds every dollar in 30 days.
90460 vs. 90461 usage reviewed across all vaccine encounters. VFC compliance confirmed. Product code accuracy for all administered vaccines verified. Revenue gap quantified by vaccine type.
96110, 96127, 99173, 99172, and 83655 billing rates reviewed against chart documentation of administered screenings. Every unbilled screening identified with monthly dollar impact calculated.
EPSDT diagnosis code compliance checked. VFC routing protocol evaluated. Same-day modifier -25 usage reviewed. Prior authorization workflows assessed for behavioral referral compliance.
Tell us about your practice and we'll show you exactly where the revenue gaps are.
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