CMS Physician Fee Schedule
The published Medicare rates and payment rules behind most of the codes on this page.
Read the sourcePediatric medical billing hinges on age-based well-child codes (99381-99394), immunization administration 90460-90474 with vaccine product capture, and modifier 25 when a sick visit lands on the same day as a well-child check. Add VFC/state-supplied vaccine tracking and adolescent confidentiality rules, and general billers miss revenue on every other visit. MedFactor delivers pediatrics-specific RCM that protects every claim.
From general pediatrics and well-child prevention to adolescent medicine and developmental-behavioral care, we tailor billing to the coding rules of every pediatric subspecialty.
Age-based E/M (99381-99394), acute sick visits (99202-99215), and routine immunization administration with vaccine product capture.
WCC new (99381-99384) and established (99391-99394) by age band, Z00.121/Z00.129 diagnosis, and Bright Futures periodicity.
Confidential adolescent visits, reproductive health, contraception counseling, and adolescent screening with appropriate V-code capture.
Same-day sick visits, modifier 25 when performed with a well-child visit, and acute respiratory/GI coding for pediatric patients.
Asthma, diabetes, and epilepsy management with chronic care coordination and care plan oversight billing.
Developmental screening (96110), autism and ADHD evaluation, and behavioral health integration codes.
Pediatric revenue lives or dies on age-based well-child codes (99381-99394), immunization administration (90460-90474) paired with vaccine product codes, and modifier 25 when a sick-visit E/M is done the same day as a well-child check. This is the largest source of pediatric claim denials.
One well-child visit bills a WCC E/M by age band, plus immunization administration per vaccine/toxoid, plus the vaccine product code — and a same-day sick visit requires modifier 25 on the E/M or it’s denied as bundled.
Pediatric billing is governed by age-based codes, immunization admin/product pairing, and modifier 25 sick-plus-well rules that general billing companies cannot navigate effectively.
Well-child 99381-99394 codes are age-banded; selecting the wrong age band (e.g. 99393 for a 4-year-old) downcodes or denies the claim.
90460/90461 administration billed without the matching vaccine product code (or vice versa) loses the full immunization reimbursement.
Well-child visits use Z00.121/Z00.129; routing them to Z01.89 (other specified exam) or retired V20.x codes drops the preventive benefit.
Sick-visit E/M (99202-99215) done same day as WCC denied as bundled when modifier 25 isn’t appended to the E/M.
Vaccines for Children (VFC) state-supplied vaccines must bill admin-only (no product charge); private-stock vaccines bill product + admin. Mixing them denies the claim.
Confidential adolescent services (reproductive, behavioral health) require sensitive diagnosis handling and payer-specific billing to protect minor confidentiality.
Quick reference for the most frequently used codes in pediatric medical billing and coding.
| Code | Description | Common Use |
|---|---|---|
| 99381–99384 | WCC new patient by age band | Newborn, 1–4, 5–11, 12–17 yr |
| 99391–99394 | WCC established patient by age | Established well-child preventive |
| 99202–99215 | Office E/M, sick visit | Acute / problem-focused visit |
| 90460 | Immunization admin, first vaccine/toxoid | First component of a vaccine series |
| 90461 | Immunization admin, each additional | Each additional vaccine/toxoid component |
| 90471–90474 | Vaccine admin by route (IM/SC/PO/nasal) | One vaccine product administration |
| 96380 / 96381 | Admin via specific routes | Therapeutic/prophylactic administration |
| G0010 | Administration of influenza vaccine | Medicare flu admin (rare in peds) |
| 96110 | Developmental screening | Standardized developmental screening tool |
| 99460 / 99461 | Newborn care in hospital/nursery | Initial normal newborn E/M |
| Code | Description | Clinical Context |
|---|---|---|
| Z00.121 | Encounter for routine WCC with abnormal findings | Well-child with abnormal finding |
| Z00.129 | Encounter for routine WCC without abnormal findings | Standard well-child visit |
| Z76.1 | Encounter for health supervision of healthy child | Health exam / supervision |
| Z23 | Encounter for immunization | All vaccine administration |
| J06.9 | Acute upper respiratory infection | Acute URI sick visit |
| R51.9 | Headache | Symptom-based sick visit |
| R50.9 | Fever, unspecified | Fever evaluation |
| B34.9 | Viral infection, unspecified | Viral illness workup |
| K59.00 | Constipation, unspecified | Common pediatric complaint |
| J45.909 | Unspecified asthma, uncomplicated | Pediatric chronic condition |
| Modifier | Description | Pediatric Application |
|---|---|---|
| 25 | Separate E/M same day | Sick-visit E/M with same-day WCC / immunization |
| 33 | Preventive service | ACA preventive / well-child services |
| 24 | Unrelated E/M in postop global | Unrelated visit during surgical global period |
| 50 | Bilateral procedure | Bilateral tympanostomy / bilateral procedures |
| 52 | Reduced service | Partially reduced procedure |
| 95 | Telehealth via interactive audio/video | Pediatric telehealth visits |
| GT | Telehealth service (legacy) | Some payer telehealth claims |
| GA | Waiver of liability statement | ABN for non-covered service |
Comprehensive revenue cycle management designed specifically for pediatric practices.
Specialty coders handle age-based WCC 99381-99394, immunization admin 90460-90474 with product capture, and modifier 25 sick-plus-well with accuracy.
Age-band correction, admin/product pairing fixes, and modifier 25 appeals with documentation for pediatric denials.
VFC state-supplied vs. private-stock vaccine tracking, admin-only billing for VFC, and full product+admin capture for private stock.
Prioritized follow-up on aged WCC, immunization, and sick-visit claims with strategic payer escalation to maximize recovery.
Regular audits focused on age-band WCC capture, modifier 25 same-day, VFC inventory reconciliation, and Z00 vs Z01 diagnosis routing.
Real-time dashboards tracking immunization rate compliance, WCC capture by age band, and physician productivity.
Understanding the most common denial reasons is the first step to preventing them on well-child, immunization, and sick-visit claims.
Wrong age-band WCC code (e.g. 99393 for a 4-year-old) downcodes or denies the preventive claim.
Age-driven code selection validating date of birth against the WCC age band at claim build.
90460/90461 administration billed without the matching vaccine product, or product billed without admin.
Pair every admin code with the matching product code and validate component counts per vaccine.
Sick-visit E/M done same day as WCC denied as bundled when modifier 25 isn’t appended to the E/M.
Modifier 25 on the E/M with separate documentation of the distinct problem addressed.
VFC state-supplied vaccine billed with a product charge, or private-stock billed admin-only, triggering denial.
VFC inventory reconciliation: admin-only for state-supplied, product+admin for private stock.
Identifying and plugging these common revenue leakage points can significantly improve your practice’s bottom line.
Well-child code selected for the wrong age band, downcoding the preventive visit.
Immunization administration billed without the matching vaccine product code.
Same-day sick visit not billed with modifier 25, losing the E/M reimbursement.
VFC state-supplied and private-stock vaccines billed against the wrong inventory.
See how pediatrics-specific revenue cycle management transforms your practice’s financial performance.
A structured onboarding process designed to deliver measurable improvements within the first 90 days.
Review of pediatric billing operations, WCC age-band capture, immunization admin/product pairing, and revenue baseline.
EMR and immunization registry integration, dedicated pediatrics billing team, and payer enrollment verification.
Full billing with real-time claim submission, modifier 25 verification, and VFC inventory reconciliation.
Performance review against baseline, immunization rate reporting, and documented revenue improvement.
How our pediatrics-specific approach compares to in-house billing and general medical billing companies.
| Capability | In-House Team | General Billing Co. | MedFactor Pediatrics |
|---|---|---|---|
| Age-band WCC 99381-99394 capture | Inconsistent | ✕ | ✓ |
| Immunization admin + product pairing | ✕ | ✕ | ✓ |
| Modifier 25 sick + well same-day | Inconsistent | ✕ | ✓ |
| VFC vs. private-stock vaccine tracking | Manual | Partial | ✓ |
| Z00 WCC vs Z01.89 routing | Inconsistent | Partial | ✓ |
| Adolescent confidential billing handling | Inconsistent | Partial | ✓ |
| Developmental screening 96110 capture | Manual | Partial | ✓ |
| Immunization rate compliance reporting | ✕ | ✕ | ✓ |
| Dedicated pediatrics billing team | ✕ | ✕ | ✓ |
Our team combines deep pediatric billing expertise with the technology and processes to deliver consistent, measurable results for well-child, immunization, and adolescent-care practices.
Discover exactly where your pediatric practice is losing revenue. Our no-obligation audit analyzes your WCC age-band capture, immunization admin/product pairing, and modifier 25 compliance.
Real results from pediatric practices that partnered with MedFactor for specialty revenue cycle management.
A general pediatrics practice was selecting wrong age-band WCC codes and missing modifier 25 on same-day sick visits. MedFactor implemented age-driven code selection and modifier 25 protocols, recovering preventive and sick-visit revenue in eight months.
A multi-provider pediatric group was billing immunization administration without the matching vaccine product codes across thousands of visits. MedFactor paired every admin with the correct product code, capturing substantial annual immunization revenue.
An adolescent and chronic-care pediatric clinic struggled with confidential billing and chronic condition capture. MedFactor implemented sensitive-diagnosis handling and chronic care coordination coding, lifting net collections across the practice.
No matter where your pediatric practice operates, our team understands the payer landscape and regulatory requirements in your region.
Deep coding knowledge across Medicaid, CHIP, Medicare, and commercial payers for pediatric services.
State-by-state Medicaid well-child periodicity and immunization coverage applied correctly across all 50 states.
Vaccines for Children program compliance and state immunization registry integration in every region.
Adolescent confidential services and reproductive health billing handled per state minor-consent laws.
Common questions from pediatric practices considering MedFactor’s specialty RCM services.
Well-child visits use the 99381-99394 family, split by new vs. established patient and age band. New patients use 99381 (younger than 1 year), 99382 (1 through 4 years), 99383 (5 through 11 years), and 99384 (12 through 17 years). Established patients use 99391, 99392, 99393, and 99394 for the same age bands. We validate the patient’s date of birth against the correct age band at claim build so the well-child code always matches the patient’s age and status, preventing the most common WCC denial — an age-band mismatch that downcodes or denies the preventive visit.
Immunization administration is billed with 90460 for the first vaccine/toxoid component and 90461 for each additional component in the same visit, plus a vaccine administration code from 90471-90474 selected by route (IM, SC, oral, or intranasal). Each administration is paired with the matching vaccine product (toxoid) code from the 90xxx or CPT vaccine product section, and the diagnosis Z23 is attached. We pair every administration code with the correct product code and count components per vaccine so neither the admin fee nor the product reimbursement is lost to a mismatch.
When a sick or problem-focused visit is performed on the same day as a well-child check, the sick-visit E/M (99202-99215) is billed with modifier 25 appended to indicate a separately identifiable evaluation and management service. The WCC code (99381-99394) is billed without a modifier, and the documentation must support a distinct problem beyond routine preventive care — for example an acute otitis or asthma exacerbation. Without modifier 25, the E/M is denied as bundled into the well-child visit. We append modifier 25 with separate documentation so the same-day sick visit is reimbursed.
Vaccines for Children (VFC) program vaccines are state-supplied at no cost to the practice, so VFC doses are billed admin-only — the immunization administration code (90460/90461 and 90471-90474) is billed without a vaccine product charge. Private-stock vaccines, purchased by the practice, are billed with both the administration code and the vaccine product code to recover the product cost. We reconcile the vaccine inventory against VFC and private stock at claim build so a VFC dose is never billed with a product charge (which denies the claim) and a private-stock dose is never billed admin-only (which loses the product revenue).
Adolescent confidential services — reproductive health, contraception, sexually transmitted infection testing, and behavioral health — are billed with sensitive-diagnosis handling per each state’s minor-consent and confidentiality laws. We apply payer-specific rules that suppress explanation-of-benefit disclosure to the policyholder where allowed, route confidential services to the correct confidential diagnosis codes, and verify which services a given payer will cover without parental consent in the patient’s state. This protects minor confidentiality while still capturing the reimbursement the practice is owed.
Pediatric telehealth visits bill the same office E/M codes (99202-99215) with modifier 95 (interactive audio/video telehealth) for most payers, or modifier GT for legacy payers that still require it. Behavioral health and certain acute sick visits are widely covered via telehealth, while well-child preventive visits generally still require an in-person component. We track each payer’s telehealth parity rules, originating-site requirements, and audio-only allowances so pediatric telehealth claims are paid rather than denied for missing modifiers or unsupported place-of-service codes.
MedFactor applies the same code-level precision across the full practice spectrum. See how we bill these related specialties.
CPT®, ICD-10, HCPCS, and modifier codes referenced on this page reflect the current code sets and are subject to annual updates — always verify against the current-year fee schedule before submission. KPIs and case-study figures shown are representative benchmarks, not guarantees of individual practice results.
The rules on this page are published somewhere official. These are the ones worth reading yourself.
The published Medicare rates and payment rules behind most of the codes on this page.
Read the sourceThe rules governing referrals between a practice and its own ancillary services.
Read the sourceThe coding and billing standards body whose credentials most billers and coders hold.
Read the sourceEnforcement guidance on billing compliance, and the arrangements that attract scrutiny.
Read the sourceThe procedure-to-procedure and medically unlikely edits behind most bundling denials.
Read the sourceThe specialty society covering well-child visit coding and vaccine administration guidance.
Read the sourceYour pediatric practice deserves billing partners who know well-child age-band coding, immunization admin and product pairing, and modifier 25 sick-plus-well rules — and code every claim correctly. Let MedFactor show you what specialty RCM can do.