Pediatric billing

EPSDT and the well-child schedule

Under Medicaid’s EPSDT benefit, a screening visit for a member under 21 includes a health and developmental history, an unclothed physical exam, immunizations on the ACIP schedule, lab tests including lead screening, and health education. Vision, hearing and dental care are covered, and the state must cover the treatment needed to correct or ameliorate what screening finds. States set the visit schedule and may use Bright Futures.

The Bright Futures periodicity schedule puts developmental screening at 9, 18 and 30 months, autism screening at 18 and 24 months, and maternal depression screening at the 1, 2, 4 and 6 month visits. Lead risk is assessed or screened at 12 and 24 months, based on universal screening requirements for Medicaid patients. We bill each screening the way your state’s EPSDT guide asks.

Vaccines for Children: who qualifies and what you can charge

Children 18 and younger qualify for VFC vaccine if they are enrolled in or eligible for Medicaid, uninsured, or American Indian or Alaska Native. Underinsured children qualify only at an FQHC, an RHC or a deputized site, and children in a separate CHIP program count as insured and do not qualify, under the CDC’s VFC eligibility rules. You screen and record eligibility at every visit.

Under 42 CFR 441.615, you never charge for a VFC vaccine. Medicaid pays the administration fee in its state plan, which cannot exceed the state’s regional maximum. For VFC children not on Medicaid you may charge up to that maximum, but you cannot refuse the vaccine because the family cannot pay. We report VFC and private-stock vaccine the way your state requires.

Counting vaccine components for 90460 and 90461

90460 and 90461 are for patients through age 18 when a physician or other qualified health care professional counsels the patient or family at the visit. The AAFP’s vaccine coding guide explains the count: 90460 once per vaccine for its first component, and 90461 for each additional component, a component being each antigen against one organism.

Its example is an 11-year-old’s checkup (99393) with HPV, Tdap and flu vaccines, all counseled: three units of 90460, one per vaccine, and two units of 90461 for Tdap’s two extra components. The vaccine products are reported on their own lines, and Medicaid plans and private payers may require each product’s 11-digit NDC.

Sick and well visits on the same day, and newborn claims

When a problem found at a well visit needs real work, bill the well visit and a sick visit (99212 to 99215) with modifier 25, documenting each so it could stand alone. A problem that is only noted stays part of the well visit, per AAFP’s guide to combined visits.

Normal newborns are billed with the newborn care codes: 99460 per day in the hospital or birthing center, 99461 elsewhere, and 99463 when the baby is admitted and discharged the same date. After discharge, a jaundice or feeding follow-up is an office visit, while a visit with no problem yet noted can be the first well visit (99391 with Z00.129).

A baby born to a mother on Medicaid is covered from birth to the first birthday without an application. Under 42 CFR 435.117, claims can be submitted under the mother’s Medicaid number until the state issues the baby’s own.

Why pediatric claims deny

Common reasons, with the reason codes that often carry them (codes vary by payer):

• A well visit outside the state’s schedule or the plan’s interval (CO-119)
• A code that does not fit the child’s age, such as 90460 at 19 (CO-6)
• A sick visit billed with the well visit but no modifier 25 (CO-97)
• A newborn claim the plan cannot match to a member (CO-31)
• A claim sent to fee-for-service Medicaid for a child in a managed care plan (CO-109)
• A clinician not yet enrolled with the plan on the date of service (CO-B7)

Our eligibility checks confirm each child’s plan before the visit, and our denial code guides explain what each code means and how it is fixed.

Credentialing for pediatricians

Pediatric practices enroll with the state Medicaid program, then with each Medicaid managed care plan. Under 42 CFR 438.602, the state must screen and enroll every network provider of its managed care plans, and a plan may contract with you for up to 120 days while that is pending. Our provider credentialing service handles the state, each plan and commercial payers at $189 per payer application, $150 per payer for up to 7 payers and $120 per payer for up to 20, with no setup fees.

What changes for these providers, step by step: see nurse practitioner credentialing.