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Medical Billing and Coding for Pediatric Preventive Care

The Pediatric Department is one of the most important segments of the healthcare industry. You could be a part of a large hospital chain or run an independent practice. Either way, pediatric medical billing and coding are challenging and need to be approached right.

Pediatrics is a complex specialty that addresses children’s physical, psychosocial, developmental, and mental health.  Pediatric management can commence periconceptionally and continue through gestation, infancy, childhood, adolescence and young adulthood.

Pediatric age group can be divided into three main phases – the infancy phase between birth and 2 years of age, the childhood phase from 2 through 12 years of age, and adolescence from 12 through 21 years of age.

Pediatric Preventive Medicine Service Codes

Coding for preventive medicine services can be quite challenging especially if it involves pediatric care. Common services that include under this exam are body measurements (length, height, head circumference, weight, body mass index, blood pressure) and an age-appropriate examination and history.

The preventive medicine codes are broadly categorized based on the type and the age of the pediatric patient – New vs Established and are age-appropriate CPT codes.


99381 – < 1 year

99382 – > 1- 4 years

99383 – 5-11 years

99384 – 12-17 years

99385 – >17 years

99391 – < 1 year

99392 – 1-4 years

99393- 5-11 years

99394 – 12-17 years

99395 – >17 years

Common guidelines to be followed while billing and coding preventive visits:

  • These codes are not based on time and hence the time spent by the physician during such visits is not relevant, though documented, in selecting the appropriate preventive medicine service code.
  • If an illness or abnormality is discovered, or a pre-existing problem is addressed, in the process of performing the preventive medicine service, and if the illness, abnormality, or problem is significant enough to require additional work to perform the key components of a problem-oriented evaluation and management (E/M) service (history, physical examination, medical decision-making, counseling/care coordination, or a combination of those), the appropriate office or other outpatient service code (99201–99215) should be reported in addition to the preventive medicine service code. Append modifier 25 to the office or other outpatient service code (eg, 99392 and 99213 25).
  • An insignificant or trivial illness, abnormality, or problem encountered in the process of performing the preventive medicine service should not be separately reported.
  • The comprehensive nature of the preventive medicine service codes reflects an age- and gender-appropriate history and physical examination and is not synonymous with the comprehensive examination required for some other E/M codes (eg, 99204, 99205, 99215).
  • Immunizations and ancillary studies involving laboratory, radiology, or other procedures, or screening tests (eg, vision, developmental, hearing) identified with a specific CPT® code, are reported and paid for separately from the preventive medicine service code.


  • Counseling, Risk Factor Reduction, and Behavior Change Intervention Code

These services are performed in an effort to promote health and prevent illness and injury.

CPT 99401-99404 should be reported for these services when performed and documented.

Common guidelines to be followed while billing and coding these services:

  • Codes are time-based, where the appropriate code is selected according to the approximate time spent providing the service. Codes may be reported when the midpoint for that time has passed. For example, once 8 minutes are documented, one may report 99401.
  • Extent of counseling or risk factor reduction intervention must be documented in the patient chart to qualify the service based on time.
  • Counseling or interventions are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.
  • Cannot be reported with patients who have symptoms or established illness.
  • For counseling individual patients with symptoms or established illness, report an office or other outpatient service code (99201–99215) instead.
  • For counseling groups of patients with symptoms or established illness, report 99078 (physician educational services rendered to patients in a group setting) instead.
  • The diagnosis codes reported for preventive counseling will vary depending on the reason for the encounter.
  • Remember that the patient cannot have symptoms or established illness; therefore, the diagnosis codes reported cannot reflect symptoms or illnesses.
  • Behavior Change Interventions, Individuals
  • Used only when counseling a patient on smoking cessation (99406, 99407).
  • Codes 99406–99409 may be reported in addition to the preventive medicine service codes.
  • Other Preventive Medicine Services
  • Oral Health – Application of topical fluoride varnish by a physician or other qualified health care professional
  • Pelvic Examination – Usually included in the preventive services. If the patient is having a problem, the physician can report an E/M service code (99212-99215) and append modifier -25 to substantiate the problem-specific pelvic visit is separate from the regular preventive exam performed on the same encounter.
  • Health Risk Assessment – Used to report administration of standardized health risk assessment instruments on the patient (96160) or a primary caregiver (eg, parent) on behalf of the patient (96161). Code 96161 requires that the questions and answers relate to the primary caregiver’s health and behaviors, not the patient’s.
  • Vision Screening – CPT 99173, 99174 and 99177 are reported for vision screening.
    • CPT 99173 is reported when a graduate visual acuity stimuli is employed to allow a quantitative estimate of visual acuity (Snellen chart)
    • CPT 99174 and 99177 are reported for instrument based ocular screening for esotropia, exotropia, anisometropia, cataracts, ptosis, hyperopia and myopia.
  • Hearing Screening – CPT 92551, 92552, 92567.
  • Developmental/Autism Screening and Emotional/Behavioral Assessment – CPT 96110, 96127.
    • Used to report administration of standardized developmental/autism screening instruments (96110) or behavioral/emotional assessments (96127).
    • Often reported when performed in the context of preventive medicine services but may also be reported when screening or assessment is performed with other E/M services (eg, acute illness or follow-up office visits).
    • Clinical staff (eg, registered nurse) typically administers and scores the completed instrument, while the physician incorporates the interpretation component into the accompanying E/M service.
    • When a standardized screening or assessment is administered along with any E/M service (eg, preventive medicine service), both services should be reported, and modifier 25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) may need to be appended to the E/M code to show the E/M service was distinct and necessary at the same visit.
    • Examples of both 96110 and 96127 instruments can be found online at here.
  • 90460 – Immunization administration (IA) through 18 years of age via any route of administration with counseling by physician or other qualified health care professional, first or only component of each vaccine or toxoid administered
  • +90461 – each additional vaccine or toxoid component administered

Common guidelines to be followed

  • Pediatric immunization administration (IA) codes (90460, 90461) are reported only when both of the following requirements are met:
    • The patient must be 18 years or younger.
    • The physician or other qualified health care professional must perform face-to-face vaccine counseling associated with the administration. NOTE: The clinical staff can do the actual administration of the vaccine.

(If both of the above guidelines are not met, report a non-age-specific AI code (90471-90474).

Source: Bright Futures (aap.org)