Pediatric billing services for well-child and sick care
Pediatric billing services have to keep pace with patients whose coverage changes often. Newborns move onto a parent's plan, families gain or lose Medicaid, and a child may carry both commercial insurance and Medicaid. Each change affects which payer gets the claim and which rules apply to the visit.
Fastora handles pediatric medical billing inside your existing EHR, with certified billers and coders reviewing each claim. The work builds on our core medical billing services: eligibility, coding, claim submission, payment posting and follow-up, adjusted for well-child schedules, vaccine programs and Medicaid plans.
Eligibility for newborns, Medicaid and CHIP
Newborns may be covered under a parent's plan for a short window before they are enrolled in their own right, so we track enrollment until the child appears on the plan's eligibility response. Coverage is verified at every visit, not only at registration, through our insurance eligibility checks.
When a child has both commercial coverage and Medicaid, Medicaid is the payer of last resort, so the commercial claim goes first and the Medicaid claim follows with the primary payer's payment details. Missing that order is a common reason for Medicaid denials and recoupments.
CHIP billing in Texas
Texas CHIP covers children in families that earn too much to qualify for Medicaid but cannot afford private insurance. Many health plans that offer Medicaid in Texas also offer CHIP, so the card can look similar while benefits, copays and authorization lists differ. CHIP families may owe small copays at the visit, which the front desk should collect based on the eligibility response rather than the card.
Texas Health Steps billing
Texas Health Steps is the Texas Medicaid name for the federal EPSDT benefit, which entitles children and young adults under 21 to periodic checkups and medically necessary care. Checkups are billed with the age-based preventive medicine codes, and Texas Medicaid health plan guides for THSteps describe additional claim details, such as benefit code EP1 on the CMS-1500 and diagnosis code Z23 when an immunization is given.
Health plan guides also note that a checkup and an acute care visit on the same day may need to be filed on separate claims, and that 99211 is used for a Texas Health Steps follow-up visit. Rules differ by managed care plan and are updated through the Texas Medicaid Provider Procedures Manual, so we check the current manual and the plan's guide before changing a charge template. Our Texas Medicaid billing guide covers the wider program.
Codes and rules specific to pediatric coding
Pediatric coding depends on the child's age on the date of service. The preventive medicine codes are age banded, and several screening and vaccine codes have age limits or documentation requirements of their own.
| Code | Descriptor (summary) |
|---|---|
| 99381–99385 | Initial preventive medicine visit, new patient, by age band (under 1 year through 18–39 years) |
| 99391–99395 | Periodic preventive medicine visit, established patient, by the same age bands |
| 90460 | Immunization administration through 18 years of age, any route, with counseling by a physician or other qualified health care professional; first or only component of each vaccine |
| 90461 | Each additional vaccine component administered with counseling (list separately) |
| 90471 / 90472 | Immunization administration by injection: one vaccine / each additional vaccine |
| 90473 / 90474 | Immunization administration by intranasal or oral route: one vaccine / each additional vaccine |
| 96110 | Developmental screening with scoring and documentation, per standardized instrument |
| 96161 | Caregiver-focused health risk assessment, with scoring and documentation, per standardized instrument |
Vaccine administration billing
Vaccine administration billing starts with one question: did a physician or other qualified professional counsel the family? If so, and the child is 18 or younger, 90460 and 90461 apply. If not, the 90471–90474 series is used. Each vaccine product is billed with its own product code unless the dose came from a state program.
When vaccines come from the Vaccines for Children program, the practice bills administration only and reports the product as the state requires. Texas Medicaid has stated that 90461 may not be billed by Texas Vaccines for Children providers when they give TVFC-eligible vaccines under that program, so a template built for commercial plans can cause errors on Medicaid claims.
Preventive visit plus a problem visit
If a significant, separately documented problem is addressed during a checkup, the problem-oriented E/M service is billed with modifier 25 alongside the preventive code. Our article on modifier 25 explains the documentation payers look for.
Documentation that supports pediatric claims
- Each checkup component required by the plan's periodicity schedule, including screenings and anticipatory guidance
- Name of each standardized screening instrument, with the score and the result
- Who provided vaccine counseling, and the components of each combination vaccine
- Vaccine lot, source (state program or private stock) and route
- A separate assessment and plan for any problem addressed during a well visit
- Referral numbers for specialist and therapy visits that need them
Common denials and how we prevent them
Most pediatric billing denials repeat in a few patterns. We fix them at the source, such as the charge template or the registration step, rather than only correcting the claim.
| Denial pattern | Prevention step |
|---|---|
| Age-specific code billed outside its age range | Check the date of birth against the code's age band during claim review |
| Counseling-based vaccine codes without documented counseling | Use 90471–90474 unless counseling by a qualified professional is recorded |
| Preventive visit beyond the plan's frequency | Confirm the last checkup date and the plan's schedule before the visit |
| Medicaid billed before commercial coverage | Apply coordination of benefits and attach the primary payer's payment details |
| Screening billed without a named instrument | Hold the charge until the instrument and score are recorded |
Denied claims go through our denial management workflow, and Medicaid managed care claims are tracked plan by plan, since each plan sets its own portal and filing limits.
Credentialing for pediatric practices
Pediatricians, nurse practitioners and physician assistants need to be enrolled with each payer before they see patients under that plan. Texas practices that see Medicaid and CHIP patients enroll with Texas Medicaid through TMHP and then credential with each managed care plan they want to join. Fastora tracks this through a nine-stage process, from document collection and CAQH setup to payer applications, panel submissions and final approval, so new clinicians are ready to bill.
How Fastora supports pediatric medical billing
Each practice has a dedicated account contact, a transparent dashboard and a monthly review call covering denials, Medicaid plan AR and patient balances. We sign a Business Associate Agreement before accessing PHI and work under the user access your practice grants. Family balances are handled with clear statements and payment plans, and pricing is quoted after a free billing assessment.
Children with allergy and immunology needs are often seen alongside general pediatrics; see allergy and immunology billing for testing and immunotherapy rules.
Pediatric billing and coding for practices and therapy providers
As a pediatric billing company, we handle pediatric billing and coding for pediatricians, pediatric specialists and therapy providers serving children. Pediatric claims bring their own rules — well-child coding sequences, vaccine administration and VFC reporting, Medicaid-heavy payer mixes with state-specific quirks, and guardian billing that keeps statements addressed correctly. Pediatric therapy billing services cover the OT, PT and speech side: timed codes, authorization by visit count, and documentation that satisfies the school-district and Medicaid reviewers who scrutinize therapy claims for children. Related: occupational therapy billing, speech therapy billing, eligibility verification.