A healthy patient financial experience is critical for pediatric providers. Errors in pediatric billing, coding, or documentation can lead to unfavorable outcomes such as unnecessary denials, prior authorization issues, and delayed billing, all of which create financial strain for families and reduced reimbursement for practices.
To support accurate billing practices, the American Academy of Pediatrics (AAP) has released its 2025 Coding for Pediatric Preventive Care guide. This document serves as a valuable resource for training and educating teams involved in pediatric billing services. We’ve summarized the key sections to help you stay informed. For full details, visit the AAP website.
Preventive Medicine Service Codes
Preventive medicine service codes (99381 – 99385 for new patients, 99391 – 99395 for established patients) form the backbone of pediatric well-child visit billing. These codes cover complete age-specific evaluations, including physical exams, medical history reviews, and anticipatory guidance.
Unlike traditional E/M codes, preventive codes are not time-based, they’re selected based on the scope of services provided, not the visit duration.
Key Point:
Use accurate ICD-10 codes, like Z00.121 for preventive visits with abnormal findings, to avoid denials and support proper reimbursement.
Working with pediatric billing experts like Konnext Solutions ensures that preventive care coding is accurate, compliant, and financially optimized.
Counseling and Behavior Change Intervention
Counseling codes (99401 – 99404) are used for structured health promotion discussions (nutrition, safety, mental health, etc.). These codes are time-based and should not be billed with preventive visit codes—a common pediatric billing error.
Billing Best Practices:
- Symptomatic patients:Use office visit codes for condition-specific counseling (e.g., depression).
- Group sessions:Use code 99078 for multiple participants (e.g., parenting classes).
- Documentation:Clearly record time spent and topics discussed.
Because pediatric visits often include extensive counseling, your billers must understand when to separate preventive care from problem-focused services. Konnext Solutions can provide specialized training and billing workflows to help.
Health Risk Assessments (HRAs)
HRAs are used to evaluate a child’s physical, emotional, and social well-being, helping identify risks early for timely intervention.
CPT Codes for HRAs:
- 96110– Developmental screening (e.g., milestones)
- 96127– Emotional/behavioral assessment (e.g., ADHD)
- 96150–96155– Health & behavior assessments (as applicable)
Tip:
Let Konnext Solutions handle HRA billing complexities. We navigate payer-specific rules to reduce denials and ensure accurate reimbursement.
Vaccines and Immunizations
Pediatric immunization billing is complex—affected by age, multivalent vaccines, state immunization programs, Medicaid, and frequent CPT updates (e.g., COVID-19 and RSV vaccines).
Why Work With Konnext Solutions?
- Stay compliant with evolving policies
- Ensure accurate documentation
- Prevent costly errors
- Optimize your immunization revenue
Pediatric Lab Billing
Lab billing varies based on whether testing is done in-house or sent to an external lab.
| Testing Location | Billing Requirements |
| In-House | Bill venipuncture (36415) + lab CPT code |
| Outsourced | Bill specimen collection (99000 or 36415) only |
Accurate ICD-10 linkage is essential to avoid denials. Konnext Solutions can train your staff or manage this process entirely.
Can You Bill a Preventive and Sick Visit on the Same Day?
Yes, but only if the problem-focused visit involves significant, separate work beyond the preventive exam.
CPT Rules:
- Must meet E/M documentation(assessment, treatment, prescribing, etc.)
- Use modifier -25to denote a separately identifiable service
Example:
During a routine check-up, a provider manages a child’s asthma or evaluates an acute issue (like a rash). The visit qualifies for both a preventive code and an E/M code, with proper documentation.
Patient Education Tip:
Train front-desk staff to explain that dual-visit billing may result in copays or out-of-pocket costs, even during a wellness visit. Consider signage or handouts to set expectations.
Make the Most of AAP’s 2025 Guidance
The AAP’s vignettes provide real-world scenarios to help your team code with confidence. Be sure to use them in staff training.
Why Konnext Solutions?
At Konnext Solutions, we specialize in pediatric billing services, including:
- Preventive care coding
- Vaccine and lab billing
- Counseling and HRA workflows
- Dual-visit E/M support
- Risk-adjusted coding strategies
Whether you’re building an internal team or outsourcing to enhance your revenue cycle, Konnext Solutions is ready to support you.
Let’s Talk.
Ready to improve your pediatric billing outcomes? Contact Konnext Solutions today and discover how our experts can reduce errors, improve collections, and give your team the guidance they need to thrive.
