Pediatricians provide essential care for infants, children, and adolescents — often involving a wide range of preventive visits, immunizations, developmental screenings, and sick visits. Unlike other specialties, pediatric billing comes with its own set of challenges such as vaccine administration, age-specific codes, modifier usage, and Medicaid-specific rules.
Pediatrics Medical Billing Services
At Smart RCM Solutions, we specialize in pediatric medical billing and revenue cycle management for practices across the United States. From accurate coding to timely claim submission and denial resolution, we help pediatricians maintain healthy revenue while focusing on growing healthy kids.
Why Pediatric Billing Is Unique
Billing for pediatric services is much more nuanced than standard family or internal medicine. You deal with not just sick visits, but also:
- Well-Child Visits & Developmental Screenings
- Newborn Care & Hospital Rounding
- Vaccines & Immunization Admin Codes
- Medicaid Variations by State
- Coordination with EPSDT Requirements
- Time-based E/M and counseling services
Each pediatric age group demands accurate CPT, ICD-10, and HCPCS coding, as well as a solid understanding of payer guidelines to avoid denials.
Common Challenges in Pediatrics Billing
Bundling of Preventive Services
Insurers may bundle vision or hearing screenings unless coded correctly with proper modifiers.
Vaccine Billing
Both the vaccine (product) and the administration (service) must be billed, sometimes with different units and NDC codes.
Age-Specific Coding
Codes differ depending on the patient’s age group (e.g., 99381 vs. 99391). Incorrect use leads to claim rejections.
EPSDT & Medicaid Rules
Pediatric Medicaid programs often have different billing policies state by state, including modifiers and diagnosis code requirements.
Coordination of Benefits (COB)
In households with multiple insurance carriers (e.g., divorced parents), proper COB handling is essential to get paid.
Our Pediatrics Billing Services Include
✅ Well-Child Visit Coding Optimization
We ensure age-appropriate codes (99381–99395) and modifiers are used accurately.
✅ Vaccine Billing Management
We bill both product and admin codes (e.g., 90460, 90633, 90696), apply NDC codes, and ensure VFC vaccines are correctly flagged.
✅ Sick Visit + Preventive Visit on Same Day
We apply Modifier -25 properly to bill both services when applicable and supported by documentation.
✅ Newborn & Hospital Rounding Billing
We capture neonatal codes for newborn care in hospitals and follow-ups.
✅ Denial Management
Our AR team follows up unpaid claims, especially Medicaid denials due to policy-specific billing errors.
✅ Monthly Reporting
You receive detailed revenue and CPT usage reports so you can monitor vaccine reimbursements, well-visit trends, and payer performance.
Common CPT Codes in Pediatric Billing
- New Patient Well Visit 99381 – 99385
- Established Patient Visit 99391 – 99395
- Sick Visit E/M Codes 99202 – 99215
- Vaccination Admin 90460, 90461, 90471 – 90474
- Vaccine Products 90633, 90647, 90715, 90696, etc.
- Newborn Care 99460 – 99463
We also manage HCPCS codes, NDCs, and Modifiers such as:
- 25: Significant, separately identifiable E/M
- SL: State-supplied vaccines
- 59: Distinct procedural service
- 26/TC: Professional vs. technical components
Who We Serve
- Pediatric Primary Care Clinics
- Newborn Hospitalist Groups
- Pediatricians in Group Practices
- Community Health Centers (CHCs)
- School-Based Pediatric Health Programs
- Pediatric Telemedicine Providers
We are well-versed in Medicaid plans across multiple states and commercial payers such as Aetna, Cigna, BCBS, UHC, and Medicaid MCOs.
Why Choose Smart RCM Solutions?
✅ Pediatric Billing Expertise
We know the nuances of pediatric coding, vaccine billing, and Medicaid guidelines inside out.
✅ Dedicated Pediatric Billing Team
Your account is managed by billing professionals trained specifically in pediatrics.
✅ Quick Claim Submission
We submit claims within 24–48 hours and aggressively follow up to minimize A/R days.
✅ Compliance & Audit Preparedness
We help you maintain complete documentation and billing integrity in case of payer audits.
✅ Transparent Monthly Reporting
Gain insights into your pediatric CPT utilization, age-based visit trends, and payer performance.
✅ HIPAA-Compliant Workflows
We use encrypted systems, secure portals, and follow all U.S. healthcare privacy regulations.
FAQs About Pediatric Medical Billing
Q: Can I bill for both a well-child and sick visit on the same day?
Yes, if documentation supports both services, and Modifier -25 is applied correctly.
Q: How do you bill for immunizations under the Vaccines for Children (VFC) program?
We separate the vaccine (product) and the administration (service), and use Modifier -SL for state-supplied vaccines.
Q: How do you handle Medicaid-specific billing rules?
We customize your billing based on each state’s Medicaid guidelines, including EPSDT codes and required modifiers.
Q: Do you help pediatricians with credentialing?
Yes, we handle new provider enrollment, re-credentialing, and contract negotiations with commercial and government payers.
Q: How long does it take to see revenue improvements?
Most practices notice improved collections and cleaner claim submissions within the first 30–60 days of onboarding.
Ready to Simplify Your Pediatric Billing?
Let Smart RCM Solutions help your pediatric practice eliminate billing headaches, increase reimbursements, and maintain clean compliance — so you can focus on children’s health, not paperwork.
📞 Call: +1-725-245-5971
📩 Email: [email protected]
🌐 Website: www.SmartRCMSolutions.com