Pediatric Billing Services
Pediatric billing services are specialty billing and revenue cycle services built specifically for children's practices where an immunization administration coded without its counseling component, or a well-child visit and a same-day sick visit billed without the right modifier, is the difference between a fully-paid encounter and revenue that leaks a few dollars at a time across thousands of visits.
EverCure Billing handles the complete revenue cycle for pediatric providers across the United States: eligibility checks, prior authorizations, pediatric coding, claim submission, denial appeals, and aged A/R recovery. Your team looks after the kids. We make sure the well-child, vaccine, and sick-visit work you already did actually gets paid and holds up if a payer looks. That also means your front desk isn't carrying the whole billing load when staffing is short, which in pediatrics it often is.
What Are Pediatric Billing Services?
Pediatric billing services cover every financial step between a patient booking a visit and that money landing in your practice account.
For a pediatric practice specifically, that includes verifying benefits before a visit, coding each encounter with the correct CPT, ICD-10, and modifier combination including the immunization administration codes that pay separately from the vaccine product, and the modifier that lets a same-day sick visit be paid alongside a well-child check handling Vaccines for Children (VFC) state-supplied doses correctly, coding newborn care by setting, submitting a clean claim, posting the payment, appealing the denial when the payer pushes back, and chasing the balance until it clears.
General medical billing stops at "submit the claim." Pediatric billing runs on immunization administration coding, well-child-plus-sick-visit modifier discipline, VFC rules, and a heavy Medicaid/CHIP payer mix and because the visit volume is so high, small per-encounter errors compound into serious money. That combination makes pediatrics one of the easiest specialties to under-bill without seeing it happen.
Why Do Pediatric Practices Lose More Revenue Than Other Specialties?
Because pediatrics runs on high-volume, low-margin encounters where vaccine coding, preventive-plus-sick rules, and Medicaid policy all have to be exactly right and much of the loss is silent under-billing spread thin across thousands of visits. These are the specific leaks we see when we run audits on pediatric practices:
Immunization administration coding
Vaccine administration is coded separately from the vaccine product, and the with-counseling codes (paid per component for patients through 18) pay differently from the without-counseling codes. Miss the counseling code, drop the each-additional-component add-on, or forget to bill administration alongside the product, and a huge share of daily volume underpays.
Well-child plus same-day sick visit
A preventive check and a separately-identifiable sick visit on the same day is legitimate and common in pediatrics but only with a properly documented modifier 25. Missing or unsupported, the payer pays one and denies the other.
Vaccines for Children (VFC) handling
State-supplied VFC doses are billed for administration, not for the product, and often need the state-supplied vaccine modifier. Bill the product you were given for free, or fail to bill the administration, and the claim is wrong either way.
Developmental and screening services left uncaptured
Developmental screening, autism screening, and similar services are separately billable but routinely go uncoded, so real work is never billed.
Newborn care across settings
Newborn care is coded differently by setting and day, and errors here quietly lose newborn revenue.
Medicaid and CHIP payer rules
A large share of pediatric visits run through Medicaid and CHIP, which carry their own screening (EPSDT), timely-filing, and documentation rules. Miss them and clean-looking claims still deny.
We build the workflow around these six failure points, because they are where pediatric practice revenue actually disappears.
What Pediatric Billing Services Does
EverCure Billing Provide?
Insurance eligibility and benefits verification
We verify active coverage, plan type, deductible status, coinsurance, and whether the child is covered under commercial, Medicaid, or CHIP before the visit so care isn't delivered on a claim that was never going to pay the way the practice assumed.
Prior authorization support
We prepare and submit authorization requests where pediatric procedures or referrals require them, attach the required clinical documentation, follow up with the payer until a decision is issued, and track expiry dates so approvals don't lapse before the service date.
Pediatric medical coding
Our coders work from your chart notes to assign the correct CPT, ICD-10-CM, and HCPCS codes applying immunization administration and product coding, well-child-plus-sick modifier logic, VFC handling, developmental screening, and newborn care rules, and linking each diagnosis to its service so claims clear medical-necessity edits. Coding and billing are handled together, so coding errors are caught before the claim goes out, not after it's audited.
Charge entry and claim scrubbing
Every claim runs through a pre-submission check for payer-specific edits, immunization administration logic, modifier 25 support, diagnosis-to-service linkage, and Medicaid/CHIP rules before it leaves our office.
Claim submission and clearinghouse management
Electronic submission, rejection handling at the clearinghouse level, and same-day correction and resubmission on front-end rejects.
Payment posting and reconciliation
ERA and manual EOB posting, contractual adjustment verification, and underpayment identification because payers do pay below contracted rates, and across pediatric volume most practices never catch it.
Denial management and appeals
Every denial is categorized by root cause, corrected, and appealed with the supporting documentation the payer is actually asking for. We also feed denial patterns back into coding so the same denial stops repeating.
Accounts receivable follow-up and recovery
Structured follow-up on aged claims by bucket (30 / 60 / 90 / 120+ days), with priority given to higher-dollar claims and anything approaching a timely filing deadline which matters especially with Medicaid.
Patient billing and support
Clear patient statements, balance explanations, and a support line so your front desk isn't spending its day explaining coverage and coinsurance to parents.
Provider credentialing and payer enrollment
New provider enrollment, re-credentialing, CAQH maintenance, and Medicare and Medicaid enrollment so a new pediatrician in your group isn't sitting idle waiting on a payer panel.
Billing audits and compliance review
Periodic internal review of coding accuracy, immunization administration coding, modifier 25 usage, and VFC handling to reduce audit exposure before a payer finds it first with audit-defense documentation prepared for high-scrutiny codes.
Financial reporting
Monthly reporting on collections, clean claim rate, denial rate by reason, days in A/R, and payer performance in plain language, not a data dump.
Which Pediatric Services
Do You Bill?
Well-child checkups Age-appropriate preventive visits for new and established patients, coded to the age band and covered indication.
Immunizations and vaccines Vaccine product and administration billed together, with the counseling and each-additional-component logic applied and VFC state-supplied doses handled correctly.
Same-day sick visits A problem visit on the same day as a preventive check, handled through correct, well-documented modifier 25 support.
Newborn care and newborn screening Newborn care coded by setting and day, with newborn screening services captured.
Developmental and behavioral screening Developmental, autism, and related screening services coded so the work is actually billed.
Circumcision and frenotomy Newborn circumcision, circumcision revision, and frenotomy (tongue-tie release) coded to the procedure.
Ear tube insertion Tympanostomy with correct bilateral and laterality coding.
Laceration repair and fracture care Wound repair coded to length and complexity, and fracture management and casting coded to site.
Asthma and chronic condition management Ongoing management visits and related services coded to indication.
Minor in-office procedures Skin biopsy, suture and staple removal, and blood draws coded correctly alongside the visit.
Which Pediatric CPT and ICD-10 Codes
Do You Work With?
| Code Range | What It Covers |
|---|---|
| 99202–99215 | New and established patient E/M (sick) visits |
| 99381–99385, 99391–99395 | Preventive / well-child visits by age |
| 99460–99463 | Newborn care services |
| 90460, 90461 | Immunization administration with counseling (through age 18) |
| 90471–90474 | Immunization administration without counseling |
| 90476–90759 | Vaccine and toxoid product codes |
| 96110 | Developmental screening |
| 99050, 99051 | Services provided after hours / at unusual times |
| 54150, 54160 | Circumcision |
| 41010 | Frenotomy (tongue-tie release) |
| 69436 | Tympanostomy (ear tube insertion) |
| 12001–13160 | Laceration and wound repair |
| Z00.12- | Routine child health examination |
| Z23 | Encounter for immunization |
| Z38.- | Liveborn infant by place of birth |
| J45.- | Asthma |
| H66.- | Otitis media |
| R62.5- | Delayed milestones / abnormal development |
Code sets update annually and payer rules including immunization administration and Medicaid/CHIP policy update more often than that. Keeping current on both is part of the service, not an extra.
Which Modifiers Actually Decide Whether
a Pediatric Claim Gets Paid?
Significant, separately-identifiable E/M on the same day as a preventive visit or a procedure. This is the modifier pediatrics lives on: it lets a same-day sick visit be paid alongside the well-child check. Wrong or missing, and one of the two denies.
State-supplied vaccine, identifying a VFC dose so administration is billed correctly and the free product isn't billed as if the practice bought it.
Medicaid EPSDT screening service, so screening visits are flagged under the program's rules.
Distinct procedural service, used to correctly separate legitimately separate services under bundling edits.
Multiple procedures in the same session, so reduction logic is applied correctly.
Bilateral and laterality, so procedures like bilateral ear tubes are reported and paid on both sides.
Repeat procedure by the same or a different physician.
Unrelated E/M during a procedure's global period.
Preventive service, identifying services delivered under preventive-care rules.
Advance beneficiary notice and non-coverage indicators for services the payer may not cover.
How Does Compliance Work in Pediatric Billing?
Immunization administration and VFC accuracy
Vaccine administration is billed separately from product, and VFC state-supplied doses are billed for administration only, often with the state-supplied vaccine modifier. We build that logic into every immunization claim so administration is captured and free product isn't billed as purchased.
Modifier 25 discipline
Well-child plus a same-day sick visit is one of the most common and most reviewed pediatric billing patterns. We hold modifier 25 to the documentation standard so both services stand up to review.
Medicaid, CHIP, and EPSDT rules
A large share of pediatric visits run through Medicaid and CHIP, with their own screening and documentation requirements. We apply the program rules so clean-looking claims don't deny on policy.
Newborn and setting-based coding
Newborn care is coded by setting and day. We apply the correct setting logic so newborn revenue is captured accurately.
HIPAA and data security
Every EverCure Billing team member works under signed HIPAA agreements with role-based access to PHI, secure data transfer, and no PHI on personal devices or unsecured channels.
How Does
Onboarding Work?
Free billing audit
We review a sample of recent claims, denials, and your aged A/R to identify where revenue is being lost and how much of it is recoverable.
Findings and scope
You get a written summary of what we found and a clear proposal services, pricing, and timeline. No obligation to continue.
System access and setup
We work inside your existing EHR and practice management system. No migration, no software purchase, no disruption to your clinical team.
Workflow mapping
We document your visit mix, top payers, current denial patterns, and internal handoffs, then build the billing workflow around how your practice actually runs.
Go live
Claims start flowing through our process. In parallel, we begin working your existing aged A/R old money is usually the fastest win.
Ongoing reporting and review
Monthly financial reporting, a dedicated account manager, and a scheduled review call to go through what's working and what needs to change.
Typical onboarding runs about two to four weeks depending on system access and practice size.
Which EHR and Practice Management Systems
Do You Work In?
We work directly in your current system rather than asking you to change platforms. Our team has worked across eClinicalWorks, AdvancedMD, NextGen, athenahealth, Kareo/Tebra, DrChrono, Practice Fusion, CareCloud, Epic, and Cerner, along with pediatric-specific platforms.
If your system isn't listed, tell us which one you use in most cases we can be trained and productive in it within days.
Who Do We Work With?
We serve practices nationwide, with a growing footprint in Indiana and New Jersey.
What Does Pediatric Billing Cost?
Our pediatric billing services are priced as a percentage of monthly collections so our revenue only grows when yours does. Your exact rate depends on visit and procedure mix, monthly claim volume, payer mix, and which parts of the cycle you want us to handle.
There are no setup fees and no long-term lock-in contracts. If you want a specific number, the free audit is the fastest way to get one that's accurate rather than generic.
Why Choose EverCure Billing for Pediatric Billing?
We code and bill together.
In pediatrics, most lost revenue is a coding decision a missing immunization counseling code, a same-day sick visit without modifier 25, a VFC dose billed wrong. Handling coding and billing in one workflow means those errors are caught before the claim drops, not surfaced later in an audit.
We work the high-volume detail, not just the easy claims.
Immunization administration, well-child-plus-sick coding, and VFC and Medicaid rules take real attention across thousands of visits. That's the work we don't cut corners because the volume is high.
You get a named account manager, not a ticket queue.
One person who knows your practice, your payers, and your visit mix, reachable directly.
Direct access to leadership.
We're built to stay close to our clients. When something goes wrong, you're not escalating through four layers to get an answer.
Denial data goes back into coding.
Every denial reason is tracked and fed back upstream so the same error stops repeating. Most billing companies just resubmit.
Transparent reporting.
You see clean claim rate, denial rate by reason, days in A/R, and collections every month, explained clearly.
No long-term contracts.
We keep your business by performing, not by locking you in.
Is Your Pediatric Practice Leaving Money on the Table?
Most pediatric practices don't know how much immunization administration is underpaying, how many same-day sick visits are denying next to well-child checks, or how much of their aged A/R is still collectible until someone actually looks.
That's what the free audit is for. We review your recent claims, denials, and A/R and give you a written breakdown of what's recoverable and what's causing the leak. No cost, no obligation.
Frequently Asked Questions
About Pediatric Billing
Yes. Our team works with the detail pediatric billing requires administration coded separately from product, the with-counseling and each-additional-component logic, VFC state-supplied doses, and same-day well-child-plus-sick modifiers. General billing knowledge alone doesn't cover any of that.
Because a lot of the loss is silent under-billing spread across high volume a dropped immunization counseling code, a same-day sick visit that got bundled, a VFC dose billed wrong. Across thousands of visits, small errors add up fast. We code to the correct administration and modifiers so the practice captures all of its own work.
Yes. We handle both together, which is how coding errors get caught before submission rather than in an audit the single biggest source of lost pediatric revenue.
Yes. We log into your current system and work inside it. There is no software to buy and no migration required.
Both. Aged A/R is usually where the fastest recovery is available, so we start working it in parallel with new claim submission.
Yes. A large share of pediatric visits run through Medicaid and CHIP, and we apply their screening, timely-filing, and documentation rules so those claims pay.
Yes. New provider enrollment, re-credentialing, CAQH maintenance, and Medicaid enrollment are all available, either bundled with billing or as a standalone service.
All work is performed under signed HIPAA agreements with role-based PHI access, secure transfer methods, and no PHI stored on personal devices.
Start with the free billing audit. You'll get a written picture of where your revenue is leaking before you commit to anything.
Ready to Fix Your Pediatric Revenue Cycle?
Every under-coded vaccine and every aged account is money your practice already earned. Let's go get it.
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