Accurate medical coding is the foundation of successful financial operations for any pediatric practice. With the complexity of pediatric services from well-child visits and developmental assessments to immunizations and behavioral health evaluations mastering the most frequently used codes can significantly impact your practice’s revenue and efficiency.
This comprehensive cheat sheet provides pediatric practices with a quick reference guide to the most common CPT and ICD-10 codes, along with practical tips for ensuring coding accuracy and compliance.
Evaluation and Management (E/M) Codes: The Backbone of Pediatric Billing
E/M codes represent the largest portion of billing for most pediatric practices. Understanding the nuances between these codes is essential for proper reimbursement.
Preventive Medicine Services (Well Visits)
New Patients:
- 99381: Initial preventive medicine, infant (under 1 year)
- 99382: Initial preventive medicine, early childhood (1-4 years)
- 99383: Initial preventive medicine, late childhood (5-11 years)
- 99384: Initial preventive medicine, adolescent (12-17 years)
- 99385: Initial preventive medicine, adult (18-39 years)
Established Patients:
- 99391: Periodic preventive medicine, infant (under 1 year)
- 99392: Periodic preventive medicine, early childhood (1-4 years)
- 99393: Periodic preventive medicine, late childhood (5-11 years)
- 99394: Periodic preventive medicine, adolescent (12-17 years)
- 99395: Periodic preventive medicine, adult (18-39 years)
Pro Tip: Remember that preventive medicine codes include age-appropriate history, examination, counseling, anticipatory guidance, risk factor reduction, and ordering of appropriate labs/procedures. Documentation should reflect all components.
Problem-Oriented Office Visits
New Patients:
- 99201-99205: Office/outpatient visit (determined by complexity)
- 99202: Low level (straightforward MDM, 15-29 minutes)
- 99203: Moderate level (low complexity MDM, 30-44 minutes)
- 99204: Detailed level (moderate complexity MDM, 45-59 minutes)
- 99205: Comprehensive level (high complexity MDM, 60-74 minutes)
Established Patients:
- 99211-99215: Office/outpatient visit (determined by complexity)
- 99211: Minimal level (may not require physician presence)
- 99212: Low level (straightforward MDM, 10-19 minutes)
- 99213: Moderate level (low complexity MDM, 20-29 minutes)
- 99214: Detailed level (moderate complexity MDM, 30-39 minutes)
- 99215: Comprehensive level (high complexity MDM, 40-54 minutes)
Pro Tip: Since the 2021 E/M changes, code selection is primarily based on medical decision making (MDM) or time. Make sure documentation clearly supports the complexity level or time spent.
Common E/M Modifiers for Pediatrics
- 25: Significant, separately identifiable E/M service on same day as a procedure
- 59: Distinct procedural service
- XU: Unusual non-overlapping service
- GC: Service performed in part by a resident under the direction of a teaching physician
Common Pediatric ICD-10 Diagnosis Codes
Accurate diagnosis coding is essential for establishing medical necessity and ensuring proper claim payment. Here are the most commonly used pediatric diagnosis codes by category:
Respiratory Conditions
- J06.9: Acute upper respiratory infection, unspecified
- J02.9: Acute pharyngitis, unspecified
- J01.90: Acute sinusitis, unspecified
- J45.909: Unspecified asthma, uncomplicated
- J45.901: Unspecified asthma with (acute) exacerbation
- J21.9: Acute bronchiolitis, unspecified
- J44.9: Chronic obstructive pulmonary disease, unspecified
Ear Conditions
- H66.90: Otitis media, unspecified, unspecified ear
- H66.91: Acute otitis media, right ear
- H66.92: Acute otitis media, left ear
- H66.93: Acute otitis media, bilateral
- H65.9: Unspecified nonsuppurative otitis media
- H92.09: Otalgia, unspecified ear
Skin Conditions
- L20.9: Atopic dermatitis, unspecified
- L30.9: Dermatitis, unspecified
- B08.5: Enteroviral vesicular stomatitis with exanthem
- L03.90: Cellulitis, unspecified
- B00.9: Herpesviral infection, unspecified
Gastrointestinal Conditions
- K59.00: Constipation, unspecified
- A09: Infectious gastroenteritis and colitis, unspecified
- R10.9: Unspecified abdominal pain
- K21.9: Gastro-esophageal reflux disease without esophagitis
- K58.9: Irritable bowel syndrome without diarrhea
Developmental/Behavioral Conditions
- F90.0: Attention-deficit hyperactivity disorder, predominantly inattentive type
- F90.1: Attention-deficit hyperactivity disorder, predominantly hyperactive type
- F90.2: Attention-deficit hyperactivity disorder, combined type
- F84.0: Autistic disorder
- F81.9: Developmental disorder of scholastic skills, unspecified
- F80.9: Developmental disorder of speech and language, unspecified
- F91.9: Conduct disorder, unspecified
Preventive Care Z Codes
- Z00.121: Encounter for routine child health examination with abnormal findings
- Z00.129: Encounter for routine child health examination without abnormal findings
- Z00.00: Encounter for general adult medical examination without abnormal findings
- Z00.01: Encounter for general adult medical examination with abnormal findings
- Z23: Encounter for immunization
- Z71.89: Other specified counseling
Pro Tip: When coding for preventive visits, use Z00.121 (with abnormal findings) when you identify an abnormality or address a pre-existing problem during the preventive visit. This helps support any additional problem-oriented services provided during the same encounter.
Immunization Administration and Vaccine Product Codes
Vaccine coding has two components: the administration code and the vaccine product code. Both must be reported for complete reimbursement.
Immunization Administration Codes
- 90460: Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified healthcare professional; first or only component of each vaccine or toxoid administered
- 90461: Each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure) (Use 90461 in conjunction with 90460)
- 90471: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
- 90472: Each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
- 90473: Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)
- 90474: Each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
Pro Tip: Use 90460/90461 for patients through 18 years when the provider performs counseling. Use 90471-90474 for patients over 18 years or when no counseling is performed.
Common Vaccine Product Codes
- 90707: MMR (measles, mumps, rubella)
- 90710: MMRV (measles, mumps, rubella, varicella)
- 90713: Poliovirus (IPV)
- 90700: DTaP (diphtheria, tetanus, acellular pertussis)
- 90715: Tdap (tetanus, diphtheria, acellular pertussis)
- 90734: Meningococcal conjugate (MenACWY)
- 90736: Zoster (shingles)
- 90744: Hepatitis B (HepB), pediatric/adolescent
- 90633: Hepatitis A (HepA), pediatric/adolescent
- 90649-90651: Human Papillomavirus (HPV) vaccines (various types)
- 90670: Pneumococcal conjugate (PCV13)
- 90680: Rotavirus, pentavalent
- 90686: Influenza, quadrivalent, split virus
- 90672: Influenza, quadrivalent, live, intranasal
Pro Tip: When billing for combination vaccines, report the specific combination vaccine code rather than individual component codes. For the administration, report 90460 for the first component and 90461 for each additional component.
Developmental Screening and Assessment Codes
Developmental screenings are a critical part of pediatric preventive care. These are the most commonly used screening codes:
- 96110: Developmental screening, with interpretation and report, per standardized instrument (e.g., PEDS, M-CHAT)
- 96127: Brief emotional/behavioral assessment with scoring and documentation, per standardized instrument (e.g., PHQ-9, SCARED, Vanderbilt)
- 96112: Developmental test administration by physician or other qualified healthcare professional, first hour
- 96113: Developmental test administration by physician or other qualified healthcare professional, each additional 30 minutes
- 96105: Assessment of aphasia with interpretation and report, per hour
Pro Tip: Code 96110 is used for screening tools that are scored by simple addition or a similar method. Use 96112/96113 for more complex assessments that require professional interpretation.
Common Procedure Codes in Pediatrics
These procedure codes are frequently used in pediatric settings:
- 54150: Circumcision, using clamp or other device
- 69210: Removal of impacted cerumen, one or both ears
- 94375: Respiratory flow volume loop
- 94010: Spirometry, including graphic record, total and timed vital capacity
- 94640: Pressurized or nonpressurized inhalation treatment
- 92551: Screening test, pure tone, air only
- 92552: Pure tone audiometry (threshold); air only
- 95115: Professional services for allergen immunotherapy, single injection
- 17110: Destruction of up to 14 benign lesions
Tips for Accurate and Compliant Coding
1. Master Combination Visits
When providing both preventive care and addressing acute or chronic problems during the same visit:
- Report the preventive E/M service code (99381-99395)
- Report the problem-oriented E/M service code (99202-99215) with modifier 25
- Document each service separately and clearly
- Ensure the problem-oriented service is significant and would typically require a separate visit
2. Understand Vaccine Coding Nuances
- For counseling by a physician or qualified healthcare professional, use 90460 for the first component and 90461 for each additional component
- Track and report vaccine lot numbers for inventory management
- Bill the most specific vaccine codes available
- Document any vaccine counseling provided, including discussion of risks and benefits
3. Leverage Modifiers Appropriately
- Use modifier 25 when billing an E/M service on the same day as a procedure
- Use modifier 59 (or XU when appropriate) to indicate distinct procedural services
- Apply modifier 91 for repeat laboratory tests on the same day when clinically necessary
- Use appropriate modifiers for reduced or discontinued services (52, 53)
4. Avoid Common Coding Pitfalls
- Don’t report a higher level of service than documented (upcoding)
- Don’t unbundle services that should be reported with a single code
- Don’t report separate E/M services when they’re included in a procedure’s global period
- Don’t report services that aren’t clearly documented
5. Stay Current with Coding Updates
- Review CPT and ICD-10 updates annually (typically effective January 1)
- Participate in ongoing coding education
- Subscribe to coding newsletters or updates from pediatric medical billing organizations
- Conduct regular internal coding audits
6. Document to Support Medical Necessity
- Clearly document the reason for each service provided
- Link each service to the appropriate diagnosis code(s)
- Include rationale for screenings, tests, or procedures ordered
- Document time spent when billing based on time
- Include details about counseling or coordination of care
Final Thoughts: The Impact of Accurate Coding
Accurate, compliant coding isn’t just about proper reimbursement it’s about telling the complete story of the care provided to your pediatric patients. When done correctly, medical coding:
- Ensures appropriate payment for services rendered
- Reduces denial rates and rework
- Supports quality measurement and reporting
- Provides data for population health management
- Protects your practice from compliance risks
By mastering these essential pediatric codes and following best practices, your practice can optimize revenue, streamline operations, and maintain compliance with ever-changing healthcare regulations.
This cheat sheet is intended as a general reference guide. Always verify coding requirements with specific payers, as policies may vary by insurance carrier and region.