Pediatrics Billing Services

Pediatric billing looks simple from the outside and is anything but. Age-banded preventive codes, vaccine claims with two code elements per immunization, same-day sick and well visits, and a payer mix dominated by Medicaid and children’s health programs all combine into a claim set where small errors repeat at high volume. A single coding habit, applied across hundreds of well visits, is either a steady revenue stream or a steady leak.
MedPlus RCM provides medical billing, coding, credentialing, and denial management for pediatric practices, built around children’s preventive and acute care.

Pediatrics billing challenges

Vaccine billing is the most error-prone area in pediatrics. Each immunization requires two codes: one for the vaccine product and one for administration. For patients through age 18, when a physician or other qualified health care professional counsels the patient or family, administration is reported with 90460 for the first component of each vaccine and 90461 for each additional component, and components are counted, not injections. Without documented counseling, the 90471 family applies instead, counting vaccines rather than components. Counting wrong, or billing 90460 without counseling documentation, is a recurring denial and audit risk.
The same-day well and sick visit is the second challenge. When a significant, separately identifiable problem is addressed during a preventive visit, both services can be reported, with modifier 25 on the problem-oriented visit. The note must support both services distinctly, and the diagnosis coding must keep the preventive encounter primary, or families can face unexpected cost-sharing and payers can reprocess the claim as a problem visit.
Screening services add a third layer. Developmental screening with a standardized instrument, brief emotional and behavioral assessment, and vision and hearing screening are separately reportable when the tool, the score, and the interpretation are documented. Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment benefit adds its own coverage and periodicity rules, so Medicaid pediatric claims must be built to that program’s schedule, not to commercial rules.

What MedPlus RCM handles for pediatrics practices

  • End-to-end medical billing. Charge entry, claim scrubbing, submission, payment posting, and patient billing, the full cycle.
  • Medical coding. Certified coders assign current ICD-10, CPT, and HCPCS codes matched to your documentation and specialty.
  • Provider credentialing and enrollment. End-to-end enrollment with Medicaid and children’s health plans, commercial payers, and Medicare, plus re-credentialing maintenance.
  • Denial management and recovery. Every denial investigated to root cause, corrected, and appealed with documentation.
  • A/R recovery. Aged and outstanding balances audited and pursued, including balances already written off where the appeal window is still open.
  • Financial reporting. Clean claim rates, collections, denial patterns, and A/R aging visible by payer and provider.
    We serve pediatrics practices of every size, from solo clinics to multi-provider groups, across all 50 states.

Results pediatrics practices can check

MedPlus RCM maintains a 99% clean claim rate and keeps client accounts receivable under 30 days. Pricing is a performance-based percentage of successfully collected revenue: if you don’t get paid, we don’t get paid. We are 100% HIPAA compliant, and onboarding takes 2 to 4 weeks depending on practice size, with no disruption to your daily cash flow.

Frequently asked questions

Why do vaccine claims deny so often?
Because vaccine billing has two code elements and the administration element depends on age and counseling. For patients through 18 with documented counseling, administration counts components, not injections. Missing counseling documentation or miscounted components both cause denials.
Can a well visit and a sick visit be billed together?
Yes, when the problem is significant and separately identifiable from the preventive service. Modifier 25 goes on the problem-oriented visit, and the note must document both services distinctly.
Are developmental screenings separately billable?
Yes, when a validated standardized instrument is used and the tool, score, and interpretation are documented. Without that documentation, the screening bundles into the preventive visit.
Do you work with Medicaid and children’s health plans?
Yes. We bill Medicaid, children’s health programs, and commercial plans, and we build Medicaid claims to the Early and Periodic Screening, Diagnostic, and Treatment benefit rules where they apply.
How long does it take to switch our billing to MedPlus RCM?
Onboarding takes between 2 and 4 weeks depending on practice size, including data migration and payer clearinghouse setup.
What does MedPlus RCM charge?
A performance-based percentage of successfully collected revenue. If you don’t get paid, we don’t get paid.

Get a free financial audit

Find out where your pediatrics practice is losing revenue. Request a free financial audit and our specialists will review your claims, denials, and A/R.
Request your free financial audit