Confirms coverage, Vaccines for Children eligibility, and EPSDT periodicity status before the visit, so the correct billing path is set before the patient is even seen.
Pediatric Medical Billing Services
Pediatric Medical Billing Services for Well Visits, Vaccines & Sick Visits
From well-child visits and vaccine administration to sick visits, developmental screening, and newborn care, we bill every corner of a pediatric practice.
Certified Billing & Coding Support
HIPAA-Conscious Workflows
Medicaid & Commercial Payers
Most Billing Software Supported
🔒 100% confidential. We never sell your data. Privacy Policy
How We Help
What We Handle for Pediatric Practices
Thrive manages the billing side of your pediatric practice so your physicians and staff can stay focused on kids instead of chasing payers. That means selecting the correct age-banded preventive code for every well-visit, counting each vaccine component so combination vaccines are never underbilled, and applying modifier 25 the moment a sick problem is addressed during a well-child visit.
Practices that choose outsourced pediatric medical billing from Thrive get a team that already knows Vaccines for Children program rules, EPSDT periodicity schedules, and developmental and behavioral screening codes, instead of a generalist biller treating every visit the same way. Whether your practice is high-volume general pediatrics or a subspecialty group, the billing rules overlap enough to share one trained team and diverge enough that generalist billers consistently get them wrong.
HIPAA compliant
Certified Professional Coders
Nationwide Payer Coverage
95%+ clean claim rate across preventive, sick, and vaccine claims submitted the first time
Claims out the door within 48 hours of a completed encounter
AR held under 30 days on average instead of aging past 60 or 90
Practices typically see a revenue lift approaching 30% after onboarding
Pediatric Billing and Coding
End-to-End Pediatric Revenue Cycle Management
Pediatric billing runs on volume and precision at once, a busy practice can generate dozens of well-visit, vaccine, and sick-visit claims in a single day, each with its own age band, component count, and modifier rule. Here is what we handle from the first eligibility check to the final payment.
Eligibility & Benefit Verification
Prior Authorization
Secures authorization for pediatric procedures and referrals that require it, and confirms coverage for developmental and behavioral screening tools where payer policy applies.
Claims Submission & Scrubbing
Checks every preventive, sick, and vaccine claim against age banding, component counts, and modifier 25 support before a claim leaves the building.
Denial Management & Appeals
Traces denials to their actual cause, whether a missing modifier 25 or a vaccine component undercount, and appeals with the documentation each payer requires.
AR Follow-Up
Works open claims on a set schedule so high-volume well-visit and vaccine claims do not sit past 30 days unattended.
Patient Statements & Collections
Bills families clearly for the portion insurance does not cover, distinguishing preventive services from sick-visit copays.
Payment Posting & Reconciliation
Reconciles payments against the fee schedule for preventive, sick, and vaccine administration claims, so underpayment gets caught early.
Credentialing & Payer Enrollment
Keeps pediatricians credentialed and enrolled with the commercial and Medicaid payers your patients actually carry.
Reporting
Regular reporting on claim status, denial trends, and AR aging broken out by preventive, sick, and vaccine claim categories.
Pediatric Medical Billing and Coding
Pediatric CPT and HCPCS Coding Reference
A quick reference to how pediatric billing codes are organized, not a substitute for chart documentation. Useful for seeing where a specific claim fits before it is coded.
- 99381 - 99385
Preventive Medicine, New Patient
Age-banded well-visit codes for a new patient, from infancy through adolescence
- 99391 - 99395
Preventive Medicine, Established Patient
Age-banded well-visit codes for an established patient, selected by the patient's age on the date of service
- 99202 - 99215
Sick Visit E/M
Office and outpatient visits for acute illness or injury, selected by medical decision making or time
- 90460 - 90461
Vaccine Administration, With Counseling
Administration of the first and each additional vaccine component when a physician or qualified health professional provides documented counseling, for patients under 19
- 90471 - 90474
Vaccine Administration, Without Counseling
Administration codes used when counseling is not documented, or for patients 19 and older, split by injectable versus intranasal or oral route
- Vaccine Product Codes
Vaccine Products
Separate HCPCS or CPT codes identifying the specific vaccine given, billed alongside the administration code
- 99460 - 99463
Newborn Care
Initial and subsequent hospital or birthing center care for a normal newborn, including same-day admission and discharge
- 96110
Developmental Screening
Standardized developmental screening such as the ASQ or M-CHAT, billed separately from the preventive visit
- 96127
Brief Emotional/Behavioral Assessment
Standardized behavioral or emotional screening tools, such as depression or ADHD screens, billed per instrument used
- 96161
Caregiver Health Risk Assessment
Administration of a caregiver-focused screening tool, such as maternal depression screening during an infant well-visit
- 99172 - 99173
Vision Screening
Visual acuity and instrument-based ocular screening performed as part of well-child care
- 92551 / 92587
Hearing Screening
Screening audiometry and otoacoustic emissions testing
- 54150
Newborn Circumcision
Surgical circumcision performed on a newborn, using a clamp or other device
What is the difference between CPT 90460 and 90471 for vaccine billing?
Both codes report vaccine administration, but they apply to different circumstances. CPT 90460 and its add-on code 90461 apply when the patient is under 19 and a physician or qualified health professional provides documented face-to-face counseling about the vaccine. CPT 90471 and 90472 apply when counseling is not documented, when a nurse administers the vaccine without physician counseling, or when the patient is 19 or older. Billing the wrong pair for the circumstance is one of the most common vaccine administration errors.
How does the Vaccines for Children program affect billing?
The Vaccines for Children program supplies vaccines at no cost to Medicaid-eligible, uninsured, underinsured, and American Indian or Alaska Native children under 19. For a VFC-eligible child, the practice bills only the administration code, never a separate charge for the vaccine product itself. Billing the product code on a VFC-eligible claim is treated as an overpayment and is typically recouped.
Denial Patterns
Pediatric Billing Challenges That Can Trigger Denials
These are not generic billing problems. Each one is specific to how payers adjudicate well-visit, vaccine, and sick-visit claims.
Missing Modifier 25 on Same-Day Sick and Well Visits
When a provider addresses a separate problem during a well-child visit, the sick visit E/M code needs modifier 25, and without it the payer denies the second charge entirely.
Vaccine Component Undercounting
Combination vaccines like DTaP-IPV-Hib contain multiple components, and billing only one unit of 90460 instead of counting each component with 90461 systematically underbills every immunization visit.
Wrong Vaccine Administration Code for Age or Counseling
Using 90460 or 90461 for a patient 19 or older, or for a visit where counseling was not documented, instead of 90471 through 90474, causes denial regardless of which vaccine was given.
VFC Vaccine Product Billing Errors
Billing the vaccine product code for a Vaccines for Children eligible child causes an overpayment recoupment, since VFC vaccines are supplied at no cost and only the administration fee is billable.
Preventive vs. Diagnosis Code Mismatch
Linking a preventive medicine CPT code to an acute illness diagnosis, or the reverse, signals a coding inconsistency that many payers flag and deny automatically.
Missed EPSDT Periodic Visit Documentation
Medicaid EPSDT billing depends on tracking each child’s periodicity schedule, and visits billed outside the expected age window without the right justification can be denied or excluded from quality metrics.
Developmental and Behavioral Screening Underbilling
Developmental screening, behavioral assessments, and caregiver depression screening are separately billable alongside the preventive visit, and practices that bundle them into the visit fee without billing the screening codes leave reimbursement on the table.
Newborn Care Code Confusion
Billing the initial hospital newborn care code more than once across a multi-day stay, instead of using the subsequent day code for each day after the first, results in denial of the duplicate claim line.
Our Process
Our Workflow for Managing Pediatric Billing
Every step below exists because of a specific denial pattern above. Nothing here is generic.
Eligibility & Benefit Verification
We confirm coverage, VFC eligibility, and EPSDT periodicity status before the visit, so the correct billing path is set from the start.
Pediatric-Trained Coding Review
Every claim is coded by billers who count vaccine components correctly and select the right age-banded preventive code, not generalists rotating across unrelated specialties.
Pre-Submission Modifier & VFC Scrubbing
Claims are checked for modifier 25 support, VFC billing rules, and screening code capture before they reach a payer, catching the errors that cause the most denials.
Clean Claim Submission
Corrected claims go out within 48 hours, keeping your pediatric billing cycle moving instead of sitting in a queue.
Denial Root-Cause & Appeal
Any denial is traced to its actual cause, a missing modifier, a component undercount, or a documentation gap, and appealed with the documentation that specific payer requires.
AR Follow-Up & Reporting
Outstanding claims are worked on a set follow-up schedule until resolved, with regular reporting back on where your numbers stand.
Why Thrive
Why Pediatric Practices Choose Thrive
Practices that switch to a pediatric billing services company like Thrive get coders built around vaccine coding and age-banded preventive visits specifically, not generic revenue cycle coverage stretched across every specialty.
Pediatric-Focused Coding Expertise
Coders who count vaccine components and select age-banded preventive codes correctly, not as one specialty among a dozen others.
HIPAA Compliance at Every Step
Patient data is handled under strict HIPAA safeguards across intake, coding, and reporting, regardless of practice size.
Nationwide Payer Experience
Claims experience across Medicaid, Medicare Advantage, and commercial payers in all 50 states, not just regional plans.
Transparent, Regular Reporting
You get consistent visibility into claim status, denial trends, and AR aging, communicated directly by your billing team.
Audit-Ready Documentation
Coding and modifier decisions are documented in a way that holds up if a payer ever asks questions later, which matters most given how closely Medicaid EPSDT and VFC billing get audited.
Talk to a Specialist
Talk to a Pediatric Billing Expert
We will look at your current claim volume, denial patterns, and visit mix, well-visit heavy, vaccine heavy, or general, and put together a custom fee schedule and a revenue recovery estimate. No obligation.
- Free 15-Minute Practice Revenue Review
- Custom fee schedule based on your claim volume and visit mix
- No disruption to your current documentation process
Request a Pediatric Billing Review
Get a free no-obligation review of the billing steps behind your pediatric claims, from eligibility through payer follow-up.
🔒 100% confidential. We never sell your data. Privacy Policy
FAQ
Pediatric Billing FAQs
How much does pediatric medical billing cost?
Fee structures are typically based on a percentage of collections and are set after we review your claim volume and visit mix, since a high-volume well-visit and vaccine practice bills very differently than a subspecialty pediatric office. You get a custom fee schedule after your Free 15-Minute Practice Revenue Review, with no obligation to sign anything.
How long does onboarding take?
Most pediatric practices are fully onboarded within one to two weeks. We start with a free billing audit to see where claims are getting stuck, then align our coding and submission workflow to your current documentation process, with no disruption to your daily schedule during the switch.
Can you take over our existing AR and open claims?
Yes. We review your open AR, including anything already aged past 30 or 60 days, and prioritize the claims most likely to be recovered first. Older well-visit, vaccine, and sick-visit claims often still qualify for appeal well past their original denial date.
Do you bill vaccine administration and VFC claims correctly?
Yes. Our coders count every vaccine component and bill 90460 and 90461 when counseling is documented, or 90471 through 90474 when it is not, and we never bill a vaccine product charge for a Vaccines for Children eligible patient, only the administration fee.
How do you handle denied claims and appeals?
Every denial is traced back to its actual cause, a missing modifier 25, a vaccine component undercount, or a preventive-to-diagnosis mismatch, before we resubmit anything. We then file the appeal with the documentation that specific payer requires, rather than resending the same claim and hoping for a different result.
Is our patient data handled securely?
Yes. Patient data is handled under HIPAA safeguards across intake, coding, and reporting, and our billing team follows the same compliance standards regardless of practice size or claim volume.
How do we track our numbers?
You receive regular reporting covering claim status, denial trends, and AR aging, plus a direct line to your billing team any time you have a question about a specific claim. Nothing about your numbers lives in a black box you have to dig through yourself.
Do you work with pediatric practices in every state?
Yes. Our team supports general pediatrics, pediatric subspecialty, and newborn care practices across all 50 states and works with Medicaid, Medicare Advantage, and commercial payers nationwide. Your location does not change how thoroughly we work your claims or how quickly you get paid.
Free Revenue Analysis
Start With a Pediatric Revenue Cycle Review
Want to see why pediatric claims are slowing down? We will review your billing workflow, denial patterns, AR aging, payer issues, vaccine workflows, and reporting process, then outline practical opportunities to tighten follow-up and reduce avoidable delays.
- HIPAA Compliant
- Certified Billing & Coding Support
- Medicaid & Commercial Payers
- Nationwide Support