A healthy patient financial experience is critical for pediatric providers. Errors in pediatric billing, coding or documentation can lead to unfavorable outcomes such as unnecessary denials, prior authorization issues, and delayed billing – all of which can cause financial stress and extra strain on families with the added risk of reduced reimbursement for practices.
To support accurate billing practices, the American Academy of Pediatrics (AAP) has released its 2025 Coding for Pediatric Preventive Care guide [1]. This document serves as a valuable resource for training and educating team members involved in pediatric billing services. We’ve compiled a summary of the most important sections for your review. For more detailed information, you can access the full pediatric medical billing document on the AAP website.
Preventive Medicine Service Codes
Preventive medicine service codes (99381–99385 for new patients and 99391–99395 for established patients) form the foundation for billing well-child visits. These codes encompass comprehensive evaluations that include age-appropriate medical history, physical examinations, and anticipatory guidance. Unlike traditional Evaluation and Management (E/M) codes, preventive codes are not time-dependent – code selection is based on the scope of services provided, not the length of the visit.
Accurate use of ICD-10 codes, such as Z00.121 for preventive visits with abnormal findings, also supports clean claim submissions. Understanding these nuances is critical to prevent unnecessary denials and underpayments. Partnering with pediatric billing companies who specialize in preventive care coding can further enhance reimbursement accuracy and financial performance.
Counseling and Behavior Change Intervention
Counseling codes (99401–99404) are used for time-based health promotion discussions on topics such as nutrition, safety, and pediatric mental health. These codes require documentation of the time spent but should not be billed in conjunction with preventive visits – a common error in pediatric medical billing. To ensure compliance with pediatric billing services, here are key points your billers should keep in mind:
- Symptomatic patients: If counseling is related to an active condition (e.g., depression management), an office visit code should be used instead.
- Group counseling: For sessions involving multiple participants, such as parenting classes, use code 99078.
- Documentation: Billers must clearly document the counseling topics discussed and the duration of the session.
Because pediatric visits often involve extensive counseling, it’s essential that billers are properly trained to distinguish between preventive services and problem-focused care. Accurate coding is key to staying compliant and avoiding billing errors with pediatric billing services.
Health Risk Assessments
Health Risk Assessments (HRAs) for pediatric patients are specialized tools designed to evaluate the overall health and well-being of children and adolescents are an essential part of pediatric billing workflows. These assessments help healthcare providers identify potential physical, developmental, behavioral, and social risks early, enabling timely interventions to promote healthy growth and development.
CPT Codes for Health Risk Assessments
Developmental and Behavioral Screening
- 96110: Developmental screening, with interpretation and report (e.g., developmental milestone assessments)
- 96127: Brief emotional/behavioral assessment (e.g., ADHD screening)
Health and Behavior Assessment/Intervention
Sometimes used if specific behavioral health risks are assessed:
- 96150–96155: Health and behavior assessment or intervention codes (may apply depending on service scope)
Outsourcing to pediatric billing companies with expertise in HRAs can help navigate payer-specific requirements and reduce denial risk.
Vaccines and Immunizations for Children
Vaccine billing is one of the most complex parts of pediatric billing. It depends on factors such as the child’s age and specific visit components – like multivalent vaccines. Navigating state-specific program requirements, Medicaid reimbursement guidelines, and frequent CPT updates (including those for COVID-19 and RSV vaccines) can be challenging.
One of the key benefits of working with pediatric billing companies is their expertise in maintaining accurate documentation and ensuring compliance with the continually evolving immunization policies, helping to optimize reimbursement and reduce errors.
Labs
Coding for labs in pediatric medical billing varies based on the testing location. When tests are performed in-house, your staff should bill for both the venipuncture procedure (36415) and the laboratory test. If the testing is outsourced, only the specimen collection code (99000 or 36415) should be billed. Additionally, staff must be well-trained in accurate ICD-10 code linkage to help minimize denials and ensure compliance with pediatric billing services.
Other Challenges in Pediatric Billing
There are many intricacies involved in pediatric billing – one of the most common being whether both a preventive and sick visit can be billed on the same day.
According to AMA CPT guidelines, if a provider addresses a new or existing condition that requires significant additional work beyond routine preventive care, both services may be billed together. To do so, the provider must document key elements of evaluation and management (E/M), such as prescribing treatment, adjusting medications, or performing a detailed assessment.
This situation frequently arises during well-child visits when a provider also manages chronic conditions like asthma, addresses behavioral concerns alongside ADHD screening, or evaluates acute issues such as a persistent cough. In these cases, modifier -25 must be appended to the E/M code to indicate a separately identifiable service performed on the same day.
Clear communication with families is essential. Many parents assume all services during a preventive visit are fully covered. Staff should be trained to explain that when problem-focused care is provided in addition to preventive services, copays or out-of-pocket costs may apply. Consider using signage or patient handouts to help set expectations and reduce billing misunderstandings.
Maximizing Value from AAP Guidance
As you review the AAP guidelines, be sure to explore the included vignettes – they offer valuable insight into pediatric coding for real-world scenarios.
At 3Gen Consulting, we deliver comprehensive pediatric billing services with specialized expertise in preventive care, immunization billing, and risk adjustment coding. Whether you’re strengthening internal teams or evaluating pediatric billing companies to enhance your revenue cycle, we’re ready to support you. Contact us today to learn how we can help.
References
[1] American Academy of Pediatrics, “Coding For Pediatric Preventive Care 2025,” 15 February 2025. Available: https://downloads.aap.org/AAP/PDF/Coding%20Preventive%20Care.pdf.
