Coding, claims and collections for general pediatric practices, multi-provider pediatric groups, pediatric urgent care and newborn nursery coverage.
A pediatric checkup rarely bills as one line. A 2-year-old's well visit can carry a preventive code, a sick visit with modifier 25, a developmental screen, fluoride varnish and vaccine administration units, and each line follows its own payer rule. Miss one and the practice absorbs it on every visit that follows. Medicaid covered 37.4% of US children in 2024 (KFF), so state VFC and EPSDT rules decide much of the revenue. Luxen's certified medical coders fix those lines before claims go out.
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Pediatric billing services code, submit and collect claims for well-child visits, sick visits, vaccines, screenings and newborn care. One visit often combines a preventive code, a modifier 25 sick visit and vaccine administration units; in 2026 Medicare values an established patient preventive visit for ages 1 to 4 (99392) at $108.89 nationally.
Pediatric billing mixes preventive and sick care in the same visit, splits vaccines between federal and private stock, and depends on whose insurance covers the child. We bill for these practice types:
Service lines we bill: preventive and sick visits, VFC and private-stock immunizations, developmental, hearing and vision screening, fluoride varnish, newborn nursery care and telehealth visits.
Pediatric claims lose money in small lines: a missing modifier, an uncounted vaccine component, a screen scored in the chart but never charged. Dollar figures are 2026 Medicare national non-facility amounts at the $33.4009 conversion factor, before locality adjustment. Medicare does not cover preventive visits or most screenings, but CMS still publishes their values.
| Scenario | Codes | What goes wrong | $ at stake per claim | Luxen audit finding |
|---|---|---|---|---|
| Sick visit handled at a well-child visit | 99392 with 99213-25 | Problem visit billed without modifier 25, or without separate documentation, and bundled into the preventive code | $95.19 for the 99213 | Sick visits billed with a well-child visit lacked modifier 25 on 10% of claims, across 7,400 pediatric claims (Luxen claim audit) |
| Combination vaccine given with counseling | 90460, 90461 | Only 90460 billed, so additional component units never reach the claim | $8.68 per missing 90461 unit | Combination vaccines were missing at least one 90461 unit on 9% of immunization claims (Luxen claim audit) |
| VFC stock billed like private stock | 90460 with the VFC vaccine code | Vaccine line carries a charge, or lacks a modifier the plan requires, and both lines deny | $23.38 for the 90460 | Coding and modifier errors caused 21% of denials (Luxen claim audit) |
| Screening documented, never charged | 96110, 96127, 99188 | Standardized instrument scored in the chart with no charge line | $12.36 for 96110; $12.02 for 99188 | Developmental and behavioral screens documented at well-child visits went uncharged on 19% of visits reviewed (Luxen billing reviews) |
| Medicaid well-child claim incomplete | 99392 on a Medicaid claim | Required EPSDT screening components not documented or coded | $108.89 for the 99392 | Medicaid EPSDT screening components were missing on 11% of well-child claims (Luxen claim audit) |
| Child covered by both parents | 99213 | Claim sent to the plan of the parent whose birthday falls later in the year | $95.19 held until coordination of benefits is fixed | Claims for children with two parental plans went to the wrong primary plan on 5% of claims with secondary coverage (Luxen claim audit) |
Well-child visits are billed by age and by new or established status. Sick care handled in the same room is billed separately when the note supports it.
| Age | New patient | Established patient |
|---|---|---|
| Infant, under 1 year | 99381 | 99391 |
| 1 to 4 years | 99382 | 99392 |
| 5 to 11 years | 99383 | 99393 |
| 12 to 17 years | 99384 | 99394 |
| 18 to 39 years | 99385 | 99395 |
An 18-year-old moves to 99385 or 99395 even when a pediatrician still sees them. CMS publishes 2026 values of $118.57 for 99382, $108.89 for 99392 and $108.55 for 99393 (CMS fee schedule data).
Billing both is allowed. The AMA states that physicians are not prohibited from billing preventive and problem-focused E/M services performed at the same appointment, with modifier 25 on the office visit code (AMA). The problem needs work documented beyond the checkup, a significant, separately identifiable service. Commercial plans may or may not cover the second service, and the added code can create a copay, so families should hear that before they leave.
| Code | What it reports | 2026 Medicare value |
|---|---|---|
| 96110 | Developmental screening with scoring | $12.36 |
| 96127 | Brief emotional or behavioral assessment | $5.01 |
| 96161 | Caregiver-focused health risk assessment | $3.34 |
| 99188 | Topical fluoride varnish application | $12.02 |
| 92551 | Pure tone hearing screening, air only | $13.36 |
| 99173 | Visual acuity screening | $3.34 |
| 99177 | Instrument-based ocular screening, both eyes | $5.34 |
Payer bundling policies for screening codes differ, so we check each plan before coding. 96161 reports a health risk assessment given for the benefit of the patient (AAP), and CMS lets state Medicaid agencies allow maternal depression screening as a service for the child under EPSDT (CMS Informational Bulletin, May 2016).
Vaccine revenue in pediatrics is mostly administration revenue, and the code depends on age, counseling and component count.
90460 reports the first or only component of each vaccine given through age 18 with counseling by a physician or other qualified health care professional, and 90461 reports each additional component (AAP immunization coding). Past age 18, or without that counseling, administration is reported with 90471 and 90472 (CMS Medicaid NCCI Policy Manual, Chapter XI).
Components are counted per antigen. The AAP example of a DTaP-HepB-IPV, Hib and PCV15 visit reports three units of 90460 and four units of 90461, $104.86 at 2026 Medicare values. Bill only three 90460 units and $34.72 disappears from that visit.
UnitedHealthcare Community Plan requires modifier SL on both the administration and vaccine codes in Arizona, with the vaccine billed at $0.00; leave SL off and both lines deny (UHC Community Plan VFC policy). Health First Colorado has VFC administration for members under 19 reported as 90460 with 90461 on its own line, and does not pay for vaccine available through VFC (Colorado immunizations billing manual). Practices comparing Arizona medical billing or Colorado medical billing options should ask how each state's vaccine setup is built.
Many pediatric denials start at registration: whose child, whose plan, and whether a newborn is covered yet. Our eligibility verification runs before the visit, not after the denial.
Group health plans must allow special enrollment for at least 30 days after a birth, with coverage starting on the date of birth (45 CFR 146.117). A child born to a mother receiving Medicaid is covered until the first birthday, and claims may be paid under the mother's Medicaid ID until the state issues the child a number (42 CFR 435.117). Normal newborn care (99460) is worth $80.83 at the 2026 Medicare facility rate, so a no-coverage denial in the first month gets rebilled, not written off.
When parents who are not separated or divorced both cover a child, the plan of the parent whose birthday falls earlier in the calendar year is primary. If a court decree makes one parent responsible for the child's health coverage and that plan knows the terms, that plan is primary (NAIC Coordination of Benefits Model Regulation). We record the rule applied on the account so the next visit bills the same way.
Other liable coverage must pay before Medicaid does (Medicaid.gov), so claims for a child with a parent's commercial plan go to that plan first. Since January 1, 2024, states must give children under 19 twelve months of continuous Medicaid and CHIP eligibility (Medicaid.gov), so a mid-year termination denial deserves a second look. EPSDT covers enrolled children under 21 (Medicaid.gov) and requires blood lead screening at 12 and 24 months (Medicaid.gov).
The AMA states that physicians are not prohibited from billing both when both are performed, with modifier 25 on the problem-focused visit (AMA). Writing off the sick visit gives away $95.19 for each 99213. And 19% of denied claims were never reworked or appealed (Luxen billing reviews).
90460 reports the first component of each vaccine, and 90461 reports each additional component (AAP immunization coding). A five-component DTaP-HepB-IPV dose billed with 90460 alone leaves four 90461 units, $34.72, off the claim. Resubmitting the original claim to add them draws a duplicate denial: duplicate claim denials made up 9% of denials, mostly from resubmitting instead of correcting (Luxen claim audit).
Group plans must allow at least 30 days to enroll a newborn, with coverage from the date of birth (45 CFR 146.117), and deemed Medicaid newborns can be billed under the mother's ID (42 CFR 435.117). Writing off an $80.83 newborn care day because the baby had no ID gives up money the plan owes. Eligibility and coverage errors caused 24% of denials (Luxen claim audit).
States must provide 12 months of continuous eligibility for children under 19 in Medicaid and CHIP, effective January 1, 2024 (Medicaid.gov). Accepting a mid-year termination denial on a $108.89 well visit without checking the eligibility period leaves it unpaid while the filing clock runs. Timely filing caused 6% of denials, and only 4% of those were recovered (Luxen claim audit).
Most private health plans must cover HRSA-supported preventive care and ACIP-recommended immunizations for children without cost sharing (45 CFR 147.130), but a sick visit billed with the checkup can carry a copay or deductible. Practices lost 3.1% of collections to patient balances written off before a second statement (Luxen client data). Our patient billing team explains those balances to families in plain language.
We run the revenue cycle from eligibility to zero balance inside the practice management system you already use. How full-service billing works.
Certified coders review charges against your documentation and payer rules before the claim goes out, so the denial is prevented rather than appealed. Medical coding.
Aged and denied claims are worked to resolution, then the upstream cause is fixed so the same claims stop coming back. Denials and AR recovery.
Benefits are verified and authorizations secured before the appointment, which is the cheapest place in the cycle to stop a denial. Eligibility and prior authorization.
Statements, balance questions and payment plans are handled by the same team that worked the claim. Patient billing.
Payer enrollment and re-credentialing are tracked through to approval, so a lapsed credential never quietly stops payment. Credentialing.
A HIPAA-trained front-office assistant working inside your EHR on calls, scheduling, intake and referrals, alongside the billing team. Medical virtual assistant.
We work inside the systems your practice already runs, with no EHR migration for providers or front desk staff.
We sign the BAA before access, then check each day's immunization log and well-visit screenings against charges.
2 weeks
from a signed BAA to our team working your claims
About 3 weeks
to the first recovered payments on aged AR
20+ years
combined billing and coding experience
Luxen client data, 38 client practices, Jan 2024 to Jun 2026:
Vaccines were documented as administered, but product and administration charges did not always reach the claim. Luxen reconciled the immunization record against billing, identified 224 missing charges, and recovered $26,100.
Practice Administrator, multi-provider pediatric group
Newborn claims remained unpaid while temporary records and coverage information were updated after discharge. Luxen resolved 87 affected accounts, recovering $51,700 and reducing average payment time from 71 days to 28.
Billing Director, pediatric and newborn care practice
Full engagements are written up in our dental practice case study and our ambulance billing case study.
A pediatric practice can grow visit volume and still lose money when nobody reviews where claims stall. These are the numbers we put in front of practice managers each month.
| Metric | Why it matters in pediatrics | Luxen benchmark |
|---|---|---|
| Days in AR | Newborn, two-parent and Medicaid plan accounts age together | Practices that reviewed AR ageing monthly carried 12 fewer days in AR (Luxen billing reviews) |
| AR past 90 days | Newborn and coordination of benefits accounts collect here | 27% of total AR sat past 90 days in the average practice reviewed (Luxen billing reviews) |
| Top denial reasons | Modifier 25, 90461 units and eligibility repeat | The top three denial reasons accounted for 58% of denied dollars in the average practice (Luxen billing reviews) |
| Screening lines per well visit | 96110, 96127 and 99188 charged against 99381 to 99395 | Reported by provider |
| 90461 units per combination vaccine | Units should match components given | Reported by vaccine |
CPT added audio-video codes 98000 to 98007 and audio-only codes 98008 to 98015 in 2025 and deleted telephone codes 99441 to 99443 (AMA), and payer adoption still differs by plan, so reports should show denials by code. After-hours codes 99050 and 99051 are bundled under Medicare (status B), so any payment for them comes from commercial or Medicaid policy. Among practice managers, 63% could not name their top three denial reasons (Luxen Practice Manager Survey 2026); our denial and AR recovery reports name them every month.
3% to 6% of collections
Luxen's pricing generally falls between 3% and 6% of collections, depending on claim volume, specialty, payer mix, and how much of the revenue cycle your practice hands over.
Higher-volume practices usually land toward the lower end. Smaller or more complex practices land higher because there is more work per account. There is no setup fee and no exit fee, and the agreement runs month to month with 30 days notice.
A lower fee attached to weak billing is still expensive. The number that matters is what your collections do after you hire someone.
Luxen charges 3% to 6% of collections, depending on provider count, visit volume and how much Medicaid plan and vaccine work the practice carries. No setup or exit fee.
| Service line | Monthly collections | Luxen at 3% | Luxen at 6% |
|---|---|---|---|
| Well-child visits and screenings | $56,000 | $1,680 | $3,360 |
| Sick and follow-up visits | $49,000 | $1,470 | $2,940 |
| Immunization administration and vaccine product | $35,000 | $1,050 | $2,100 |
| Total | $140,000 | $4,200 | $8,400 |
| Cost | In-house | Luxen |
|---|---|---|
| Monthly | $11,060 (7.9% of collections) | $4,200 to $8,400 |
| Annual | $132,720 | $50,400 to $100,800 |
| When a biller leaves | Open biller roles took a median 67 days to fill (Luxen Practice Manager Survey 2026) | No gap in coverage |
| Terms | Salaries, benefits and software | Month to month, 30 days notice |
Fully loaded in-house billing cost 7.9% of collections for practices under $2M, across 96 practices that shared payroll data (Luxen billing reviews). The example group collects $1.68M a year.
| Partner type | Vaccine and VFC rules | Newborn and family coverage | Reporting | Terms |
|---|---|---|---|---|
| In-house biller | Depends on one person | Handled at the front desk | Built by your staff | Payroll and turnover |
| Generalist billing company | Adult E/M focus | Often not included | Standard aging reports | Often annual terms |
| Specialty pediatric billing company | Pediatric code experience | Varies | Varies | Varies, some charge setup fees |
| EHR vendor RCM | Tied to vendor templates | Varies | Inside the vendor platform | Bundled with software |
| Luxen | Certified coders for 90460, 90461 and state VFC setups | Included | Monthly denials and AR by payer and visit type | Month to month, 30 days notice |
Compare medical billing companies on these points, or see what full-service medical billing covers.
A 30-minute look at your AR ageing, denial reasons and payer mix. You leave knowing what is recoverable, what we would work first and what it would cost.
We sign a business associate agreement before anyone touches your system. Your named team then works inside the practice management system and clearinghouse you already use. Nothing is migrated, and claims are being worked within two weeks of the signed BAA.
Aged and denied claims come first because that is revenue you have already earned. Most practices see the first recovered payments inside three weeks.
Once the backlog is moving, we take over the agreed part of the daily cycle: eligibility, coding review, submission, posting, denials and patient balances.
You know who owns your claims. The team works inside the practice management system and EHR you already run, with no migration.
Claims are coded by certified coders against your documentation and payer rules. Automation handles the repetitive checks so people spend their time on the claims that need judgment.
We sign a business associate agreement before accessing protected health information, and access is limited to the named people on your account.
We look at your AR ageing, volume, payer mix and denial profile first, then tell you what we believe is recoverable and what it would cost.
A billing company is a poor fit if you are not willing to share visibility into your billing, if the vendor uses a rotating pool of people who never learn your practice, or if it cannot explain why your claims are being denied. Be wary of anyone promising large collection increases before they have seen your AR ageing. The right partner makes your revenue cycle more visible, not less.
Well-child visits are billed with preventive medicine codes chosen by age and patient status: 99381 to 99385 for new patients and 99391 to 99395 for established patients. Vaccines add administration codes such as 90460 and 90461, and screenings such as 96110 bill on their own lines. A sick problem handled at the same visit is billed with an office visit code and modifier 25.
Luxen charges 3% to 6% of collections, with no setup or exit fee. A pediatric group collecting $140,000 a month would pay $4,200 to $8,400 a month. The rate depends on visit volume, Medicaid plan mix and vaccine billing work.
About 2 weeks from signed BAA to working claims, with first recovered payments in about 3 weeks. We work inside your current EHR, so providers and front desk staff keep their workflow. Terms are month to month with 30 days notice.
Yes. We work in Epic, athenaOne, eClinicalWorks, NextGen, Tebra, AdvancedMD and other systems, with no migration. We sign the BAA before access and match the immunization log to 90460 and 90461 charges each day.
No. AAP guidance says not to report 90460 to 90461 or 90471 to 90472 for RSV immunization, because those codes are limited to vaccine and toxoid products. Report the product and its administration with the codes AAP lists for RSV immunization, and check each plan's policy for the season.
Thirty minutes, no deck and no fee. We look at what is sitting past 90 days and where your denials cluster, and you leave knowing what is recoverable, what we would work first, and what it would cost.
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