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Pediatrics Billing: focusing on vaccines and preventive medicine claims

February 26, 2019

Pediatrics BillingPreventive medicine is one of the most critical components of providing care for infants and children by pediatricians.  Due to recent changes in CPT vaccination codes as well as billing requirements by payers, reimbursement for even the most routine vaccinations, as well as preventive exams, can become a billing challenge. Another loss of revenue for many pediatric providers is failure to maximize reimbursements by undercoding and omitting modifiers as well as submitting claims without supporting documentation.

We’ll take a look at some of the more complex billing codes, including determining which items are billable and included in preventive services as well as special considerations for government programs, to help ensure appropriate reimbursement.

Preventive-care exams

Routine preventive-care exams and appropriate ICD-10 CM coding/ modifiers in order of age range as follows:

Z00.110 – Health examination for newborns under 8 days old

Z00.111 – Health examination for newborn 8-28 days old

Z00.121 – Encounter for routine child health examination (over 28 days old) with abnormal findings

Z00.129 – Encounter for routine child health examination (over 28 days old) without abnormal findings

For most pediatric patients age 18 or older, the following codes usually apply.  (Keep in mind that the designation as “adult” may depend on the insurer and state regulations, with some payers applying age-edits to other CPT and ICD-10-CM codes for preventive services.)

Z00.00 – Encounter for general adult medical examination without abnormal findings

Z00.01 – Encounter for general adult medical examination with abnormal findings

It should be noted that the ICD-10 billing codes referenced above include routine vision, hearing and developmental screening services, with no additional diagnosis code or modifier required.

A quick word about E/M billing: if a chronic but well-managed condition being evaluated is stable and closely related to the preventive visit/ exam, such as well-controlled asthma that doesn’t need a medication change, submitting an E/R code isn’t warranted.


Administering vaccines is an area where many pediatricians lose revenue: for example, counseling may have been provided but not documented or perhaps not reflected on the billing statement.

Before you can bill for vaccinations, you need to be aware of these factors before you can choose the appropriate administration codes:

  • Did the physician provider counseling?
  • Location/ route of the vaccine and administration method: (nasal, intramuscular, etc.)
  • How many vaccines were administered during the visit?
  • How many components or toxoids were in each vaccination?

New codes

In 2011, two new CPT codes, 90460 and +90461, replaced 90465–90468. These are quite different from the existing codes 90471-90474 in that they include counseling by the physician 9or other qualified healthcare provider) and are based on the number of components in a vaccine, rather than the number of vaccines provided. Furthermore, the route of the vaccination isn’t part of the new codes.

Taking a closer look at 90471-90474, we see that they’re used when a provider doesn’t counsel a patient on the administered vaccine. 90471 and 90472 apply to intramuscular injection, the most common route of administration. 90473 and 90474 are codes for vaccines given via the intranasal or oral route.

Single or multiple components

90471-90473 apply to an initial or first vaccine administered (only one type of code can be used at any given encounter.)

Multiple vaccinations

  • +90472 – Applies to each additional vaccine (single or combination) and should be listed separately in addition to the code for the primary immunization procedure.
  • Note that if an injectable and an intranasal/ oral vaccine are administered during the same visit, report as 90471 as the initial administration code.
  • When three or more vaccines are administered during a single visit, additional units should be applied to subsequent administration codes for each additional vaccine of the same route (intramuscular, oral or intranasal.)

Vaccines for Children Program: special considerations

Some medical practices choose to participate in the federally-funded Vaccines for Children (VCF) program, through which states provide vaccines to practices for administration to children under age 18 who meet certain criteria. Normally, when billing for immunizations, both the procedure and the product (vaccine) are paid for when provided.

However, within the VCF program, providers are not allowed to charge beneficiaries for vaccines, nor are separately reimbursed by commercial carriers or Medicaid for the vaccine (drug) itself. Providers may, however, charge an administration fee for providing the vaccine.

State-specific coding requirements as well as those of local carriers for immunizations when using vaccines supplied through the Vaccines for Children Program can vary – be sure that you understand your state’s rules for immunization claims through this program.

Be aware of policy and coding changes in payer billing guidelines

Following the implementation of plans with no out-of-pocket costs regarding recommended preventive services by the Affordable Care Act, many payers have established policies with specific coding requirements affecting reimbursement of preventive services. Your billers need to verify the coding and other policy edits information with the various payers you work with, as amounts and requirements can vary depending on plans and payers.

Finally, remember that coding as well as modifier requirements for Medicaid can vary for services, even within the same state. Your practice needs to be familiar with each contractor’s guidelines for Early and Periodic Screening, Diagnostic and Treatment Services program as well. Familiarity with your state’s Medicaid reimbursement, CPT changes and guidelines as well as those of your most common payers will ease coding, reduce claim denials and increase your chances for correct reimbursement.

Team with an experienced pediatrics billing partner

Working closely with an experienced medical claims billing and practice management service can go even further to help your practice realize the reimbursement to which it’s entitled. Since 2002, M-Scribe has helped many pediatric practices of all specialties and sizes, from solo practices to larger organizations, take control over their revenue cycles and manage all aspects of growing a practice.

Contact M-Scribe at 770-666-0470 or email us to learn more about saving money and growing your practice’s income while ensuring full compliance with all government and insurance payer requirements.


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