Various sources have reported that the rate of claim denials for pediatric services is one of the highest among all medical specialties. According to the American Academy of Pediatrics (AAP), the average claim denial rate for pediatricians is 13%, whereas the overall denial rate in the healthcare industry is 5-10%.
Unfortunately, many of the claims are denied because of coding errors. Mistakes like incorrect codes, missing modifiers, upcoding, and downcoding cost healthcare practices nearly $36 billion annually! However, the situation is not as dire as it seems. You can prevent revenue leaks from claim denials by knowing the most common pediatric CPT codes in 2024. From routine checkups to antibody immunizations, these CPT codes cover the most sought-after child healthcare services. Take a look!
- Most Used Pediatric CPT Codes of 2024
- Pediatric CPT Codes for E/M Visits
- Pediatric CPT Codes for Newborn Care Services
- Pediatric CPT Codes for Immunization
- Pediatric CPT Codes for Preventative Care
- Pediatric CPT Codes for Counseling, Preventative Medicine & Risk Reduction
- Pediatric CPT Codes for Chronic Care Management
- Pediatric CPT Codes for Principal Care Management
- Conclusion
Most Used Pediatric CPT Codes of 2024
Around 21.56% of the US population (74.6 million) are children. Citizens between the ages of 0 and 17 are part of this group. Specifically speaking, the group includes newborns, infants, toddlers, school-aged children, and adolescents.
Healthcare professionals offering services to this age group are known as pediatricians and pediatric nurses. From preventive care checkups to chronic care management and vaccinations/immunizations to individual and group counseling, they offer a spectrum of medical services to children under 18. All these services must be reported using the latest pediatric CPT codes list maintained by the American Medical Association (AMA).
Below, we have listed the popular pediatric CPT codes of 2024 that frequently appear on insurance claim forms filed by pediatric practices.
Pediatric CPT Codes for E/M Visits
CPT codes 99202 to 99215 are used when new and returning infants, children, and adolescents visit a pediatrician’s office, outpatient facility, or emergency room for timed evaluation and management services. The correct codes are reported based on the status of the patient, the time the provider spends on each session, and the degree of medical decision-making.
CPT Codes 99202-99205 – Evaluation and Management Visits for New Patients
Pediatric practices must refer to the evaluation and management CPT codes list 99202 to 99205 when a new patient between the ages of 0 and 17 visits their office (outpatient visit). Depending on the degree of medical decision-making, these encounters last between 15 and 60 minutes, allowing the healthcare provider to assess the patient’s well-being and offer appropriate treatment suggestions.
The table below lists the pediatric CPT codes for E/M visits alongside their medical assessment levels and the duration of the visits.
| Pediatric CPT Code for E/M | Level of Decision-Making | Duration of the Visit |
|---|---|---|
| 99202 | Straightforward | 15+ minutes |
| 99203 | Low-level | 30+ minutes |
| 99204 | Moderate | 45+ minutes |
| 99205 | High-level | 60+ minutes |
CPT Codes 99212-99215 – Evaluation and Management Visits for Established Patients.
Likewise, when child specialists meet established or returning patients, aged 0-17, in their office or an outpatient setting, pediatric CPT codes 99212 to 99215 are reported to notify the insurance payer about these encounters and seek reimbursements against them. Again, the codes must be reported based on the time the provider spends with the patient and the degree of medical-decision making, as shown in the table below.
| Pediatric CPT Code for E/M | Level of Decision-Making | Duration of the Visit |
|---|---|---|
| 99212 | Straightforward | 10+ minutes |
| 99213 | Low-level | 20+ minutes |
| 99214 | Moderate | 30+ minutes |
| 99215 | High-level | 40+ minutes |
Pediatric CPT Codes for Newborn Care Services
Around 10,000 babies are born in the USA each day. While 8.6% of these births are low-weight and 10.38% are premature, the rest are normal but still require some level of medical care.
Hence, pediatric CPT codes 99460 to 99463 cover neonatal care services for newborn infants in a hospital setting/birthing facility or outside it. The care starts right after the baby’s birth and lasts until the baby is discharged or left in the mother’s care.
CPT Code 99460 – Newborn Care for Normal Infant In the Hospital
Pediatric CPT code 99460 is used on the claim form when the provider cares for a healthy newborn infant in a hospital or birthing center. He evaluates and manages the neonate’s health immediately after the birth and until the baby is discharged.
One 99460 code must be reported for a day of newborn care. So, if the provider cares for the baby for 3 days, then three separate claims should be filed.
CPT Code 99461 – Newborn Care for Normal Infant, Outside the Hospital
However, pediatric CPT code 99461 is reported for initial care per day when a normal, healthy baby is offered newborn care outside the hospital or birthing center. The provider monitors the newborn’s health and manages non-threatening conditions like bilirubin checks to ensure the baby is ready to transition from medical to maternal care.
Pediatric CPT Codes for Immunization
In July 2024, UNICEF found that nearly 4.4 million deaths can be avoided if countries provide routine immunization services to their children. Therefore, vaccinations have become one of the most cost-effective public health intervention methods.
In the United States, the Advisory Committee on Immunization Practices recommends that newborns and infants should be vaccinated against 15 potentially serious illnesses before they turn 24 months old. Hence, childcare specialists often report the following pediatric CPT codes, covering the recommended immunizations.
CPT Code 91318 – COVID-19 Vaccine, Pfizer, Child Aged 6 Months to 4 years
According to the Centers for Disease Control and Prevention (CDC), by the end of December 2022, around 10.1% of the children between ages 6 months and 4 years had received a COVID-19 vaccine dose. Even though the peak of the pandemic has subsided, coronavirus vaccines are still popular in children and adults alike.
Pediatric CPT code 91318 is assigned when a child aged 6 months to 4 years is given 0.3 mL/3 mcg of SARS-COV-2 (COVID-19) vaccine developed by Pfizer-BioNTech for immunization against severe acute respiratory syndrome coronavirus 2. The tris–sucrose formulation or dose is administered intramuscularly.
CPT Code 91321- COVID-19 Vaccine, Moderna, Child Aged 6 Months to 11 Years
Another pharmaceutical and biotechnology company that aced the COVID-19 vaccine development race with 95% efficacy was Moderna. Therefore, pediatric CPT code 91321 is reported when children aged 6 months to 11 years are given 2.25 mL/ 25 mcg of Moderna SARS-COV-2 (COVID-19) vaccine shot, intramuscularly, for prevention against severe acute respiratory syndrome coronavirus 2.
CPT Code 90380 – RSV Monoclonal Antibody, Intramuscular Vaccine, 0.5 mL Dose
Respiratory syncytial virus (RSV) is a highly contagious respiratory disease that affects 58,000–80,000 children (younger than 5 years of age) annually in the USA. Its symptoms include troubled breathing, lethargy, and wet cough. Luckily, vaccination against RSV is widely available and highly recommended.
Pediatric CPT code 90380 is used when babies younger than 8 months and weighing less than 5 kilograms are given 0.5 mL of a monoclonal antibody product intramuscularly for prevention against RSV. The dosage is most effective right before the RSV season, which lasts from fall to spring.
CPT Code 90381 – RSV Monoclonal Antibody, Intramuscular Vaccine, 1 mL Dose
Infants younger than 8 months but weighing equal to or more than 5 kilograms are given 1 mL of RSV monoclonal antibody product directly into the muscle for immunization against respiratory syncytial virus. This seasonal dose is reported using pediatric CPT code 90381.
CPT Code 90686 – Influenza Virus Vaccine, Intramuscular, 0.5 mL Dose
Every year, 47.7% of children between the ages of 6 months and 17 years are given influenza vaccinations in the country. Influenza and pneumonia are ranked the 12th leading cause of death in the USA. Therefore, vaccination against the disease is highly recommended.
Pediatric CPT code 90686 is assigned when the provider administers 0.5 mL of a preservative-free, four–strain influenza virus vaccine into the patient’s muscle to induce immunity against influenza.
CPT Code 90710 – Measles, Mumps, Rubella, and Varicella Vaccine (MMRV)
Mumps, measles, and rubella are some of the other diseases that are prevalent among children. Every year, around 90.8% of children are vaccinated against measles, mumps, and rubella (MMR) before they turn 24 months.
The pediatric CPT code 90710 denotes that the provider administered a live combination of measles, mumps, varicella, and rubella virus vaccines for protection against these diseases. The dosage is administered subcutaneously.
Pediatric CPT Codes for Preventative Care
The American Academy of Pediatrics recommends that infants should be taken to their doctor every three months for preventative healthcare visits (also known as well-baby visits), whereas toddlers (30 months of age and above) and children until age 10 should visit their pediatrician once every year.
These scheduled well-baby, well-child, or well-patient visits help the provider assess and inform parents about their child’s growth and development, preventing serious illnesses or disorders. The following pediatric CPT codes cover such preventative care sessions and services.
CPT Code 99381 – New Patient, Well-Baby Visit for An Infant
Pediatric CPT code 99381 refers to a well-baby visit for a child under the age of one. During this preventative care visit, the provider performs routine examinations, like measuring the child’s height, weight, and head circumference, to see how well the child is growing.
For development, the provider may test the infant’s vision and hearing (not through formal screenings) and ask parents about other milestones like standing or crawling. Some providers may also perform blood tests to check for conditions like anemia, while some comprehensively educate the parents on child safety, e.g., baby-proofing the house or using car seats.
CPT Code 99383 – New Patient, Well-Patient Visit for Child, Aged 5-11
When the provider meets a new patient who is between 5 and 11 years of age for a well-child or preventative care visit, the pediatric CPT code 99383 is reported. Again, the provider assesses the child’s growth and well-being through several tests, like blood screening, eye testing, and height and weight measurements, to ensure that the child is experiencing normal growth without any chronic conditions.
CPT Code 99384 – New Patient, Well-Patient Visit for Adolescent, Aged 12-17
Adolescents between the ages of 12 and 17 are also advised to routinely visit their family doctors for well-patient visits (at least once a year). Pediatric CPT code 99384 denotes such a session but with a new patient. Similar health checkups are conducted to rule out chronic diseases and disorders.
CPT Code 99391 – Established Patient, Well-Baby Visit for An Infant
Pediatric CPT code 99391 is quite similar to code 99381. However, for code 99391, the provider has previously treated the infant (still under the age of one). During the well-baby visit, the provider takes down the infant’s family history, orders diagnostic tests like blood and urine screenings, and suggests immunizations to protect the baby against diseases and disabilities.
The code is reported for one such thorough assessment conducted periodically until the child turns 30 months of age.
CPT Code 99393 – Established Patient, Well-Patient Visit for Child, Aged 5-11
In this case, too, the pediatric CPT code 99393 is similar to code 99383. The provider offers preventative care or well-child services to a patient aged 5 to 11. The only exception is that the patient is a returning one.
CPT Code 99394 – Established Patient, Well-Patient Visit for Adolescent, Aged 12-17
Pediatric CPT code 99394 is used when an established patient who is an adolescent between the ages of 12 and 17 visits the provider’s office for routine preventative care or well-patient checkup. The provider can perform several tests, like checking the cholesterol and blood sugar levels, and advise the patient on age-related issues like puberty to help them manage their well-being.
Pediatric CPT Codes for Counseling, Preventative Medicine & Risk Reduction
Preventative medicine and risk factor reduction counseling sessions are separate from preventative care services offered to infants and children aged 0-17.
This pediatric CPT codes list, from code 99401 to 99412, covers individual and group counseling to understand the patient’s social and family history and address areas of concern like substance abuse, bad diet, lack of exercise, unprotected sex, and domestic abuse.
CPT Codes 99401-99404 – Preventive Medicine Visit, Individual Counseling
Pediatric CPT code range 99401 to 99404 covers individual counseling for preventive medicine. All of these are time-based codes and describe face-to-face meetings between the patient and the provider, as explained in the table below.
| Pediatric CPT Code | Description | Duration |
|---|---|---|
| 99401 | The provider counsels the patient on age-related subjects and assesses the patient’s family history and risk factors. The session roughly lasts for about 15 minutes. | 15 minutes |
| 99402 | The provider asks the patient about his family history to understand the areas of concern and risk factors and offer age-appropriate advice. The session extends to 30 minutes. | 30 minutes |
| 99403 | In this 45-minute-long counseling session, the patient and the provider discuss age-related subjects, including the patient’s family history, to manage risk factors. | 45 minutes |
| 99404 | This counseling session roughly lasts for around 60 minutes and includes discussions on subjects that are appropriate to the patient’s age, e.g., uncovering family history. | 60 minutes |
CPT Codes 99411-99412 – Preventive Medicine Visit, Group Counseling
Taking inspiration from traditional classrooms, healthcare providers realized the effectiveness of shared or peer-to-peer learning and started offering counseling for preventive medicine in groups.
Pediatric CPT codes 99411 and 99412 cover these group counseling sessions with children where various age-appropriate subjects are discussed to ensure patients’ physical, emotional, and psychological wellness.
| Pediatric CPT Code | Description | Duration |
|---|---|---|
| 99411 | The provider meets a group of patients and offers advice on health maintenance and improvement for half an hour. | 30 minutes |
| 99412 | The provider meets a group of patients and counsels them on health maintenance and improvement for an hour. | 60 minutes |
Pediatric CPT Codes for Chronic Care Management
CDC reports that in the USA, over 40% of school-aged children and adolescents have at least one chronic health disease or condition, which includes asthma, diabetes, obesity, and epilepsy. Chronic diseases are not curable. However, the conditions can be managed with the right medical support and lifestyle changes, allowing patients to live normal and fulfilling lives.
The following pediatric CPT codes refer to the chronic care management sessions that healthcare providers have with children aged 0 to 17.
CPT Code 99491 – Chronic Care Management, First 30 Minutes
Pediatric CPT code 99491 is for billing the first 30 minutes of an evaluation and management visit that the provider has with his young patient dealing with two or more chronic conditions. The provider personally assesses the patient’s condition, offers care services, and advises the patient and caregivers on chronic disease management.
Please note that this code is reported for one such visit per calendar month and for a patient whose chronic conditions are expected to last at least a year or until his death. Moreover, the patient must be at the risk of severe exacerbation, functional decline, deterioration, or death.
CPT Code 99437 – Chronic Care Management, Additional 30 Minutes
Providers use the pediatric CPT code 99437 when they want to bill the additional 30 minutes of a chronic care management visit. This code is used in conjunction with pediatric CPT code 99491. Therefore, the conditions for reporting 99437 are the same as the above, i.e., the child must have two or more chronic conditions that last at least a year or until his death and must be at significant risk of functional decline, deterioration, or death.
CPT Code 99487 – Complex Chronic Care Management, First 60 Minutes
Pediatric CPT code 99487 is reported for complex chronic care management office visits that last up to 60 minutes. The clinical staff, under the supervision of a pediatrician, revises or establishes a comprehensive care plan for the patient, involving moderate-to-high complexity decision-making.
The code is assigned (once per calendar month) for services offered to a patient who has two or more chronic conditions, placing him at severe risk of physical and psychological decline, acute exacerbation, and death.
CPT Code 99489 – Complex Chronic Care Management, Additional 30 Minutes
99489 is an add-on pediatric CPT code used with code 99487 to denote an additional 30 minutes of a complex chronic care management visit beyond the first 60 minutes. During the extended meeting, the clinical staff (supervised by the pediatrician) coordinates the patient’s care across multiple specialties to offer comprehensive medical support for managing complex chronic diseases.
Again, the code must be reported once per calendar month and for a patient who has two or more chronic conditions, placing him at severe risk of functional decline and death. CPT code 99489 for pediatric services should not be billed with 99491.
Pediatric CPT Codes for Principal Care Management
Principal Care Management (PCM) is a Medicare-backed care model for patients suffering from one chronic disease or condition. It is different from chronic care management (CCM) services mentioned above because, for CCM services, the patient must be diagnosed with multiple (two or more) chronic conditions.
The Centers for Medicare & Medicaid Services (CMS) first introduced PCM HCPCS (services, equipment, and drugs) codes in 2020. However, in 2022, these HCPCS codes were replaced with the pediatric CPT codes 99424, 99425, 99426, and 99427 to cover principal care management for chronic diseases in children, as explained below.
Please note that Medicare Part B offers coverage for PCM services.
CPT Code 99424 – Principal Care Management, Personally, First 30 Minutes
Pediatric CPT code 99424 is for PCM services offered to children and adolescents battling one complex chronic condition lasting at least 3 months and placing the patient at significant risk of hospitalization, acute exacerbation, physical and psychological decline, or death.
The visit lasts 30 minutes (once per calendar month) and involves management and care plan services, which the pediatrician renders personally.
CPT Code 99425 – Principal Care Management, Personally, Additional 30 Minutes
99425 is an add-on pediatric CPT code used in conjunction with code 99424 to denote an extra 30 minutes of PCM services beyond the first half-hour session. The provider personally evaluates the patient’s complex chronic condition to offer suitable management and care services.
The prolonged principal care management outpatient visit is also reported only once in 30 days.
CPT Code 99426 – Principal Care Management, Supervised, First 30 Minutes
Principal care management services can be offered virtually as well. For example, the pediatric CPT code 99426 is used when the clinical staff delivers management and care plan services to a patient suffering from one complex chronic condition under the guidance of a qualified healthcare professional.
The session lasts for 30 minutes and must occur once a month. Please note that for the patient to qualify for this PCM service, he must have one complex chronic disease that lasts at least 3 months and increases the risk of hospitalization, severe exacerbation, functional decline, or death.
CPT Code 99427 – Principal Care Management, Supervised, Additional 30 Minutes
If the PCM service denoted by code 99426 stretches to 30 more minutes, pediatric CPT code 99427 is used to indicate the additional time the clinical staff spent with the patient. As mentioned before, this is a physician-supervised PCM office visit scheduled once per calendar month. The clinical staff follows the guidance of the physician to offer management and care plan services to a patient with a complex chronic condition.
Conclusion
The Association of American Medical Colleges expects that by 2036, there will be a shortage of 86,000 physicians in the USA. These statistics come to light as the number of medical students applying for pediatrics decreased by 6%. So, what is pulling aspiring healthcare professionals away from this medical specialty?
Well, first is that children are at a greater risk of maladies as their immune system is weak and still developing. Second, the array of medical conditions associated with children widens the pediatric CPT code set, further complicating the coding procedure. The third and final reason is that coding complications lead to errors and denied reimbursements, causing a strain on the financial health of pediatric practices.
However, students can choose this specialty without worry because professional pediatric billing services include CPT coding, accurately capturing every procedure and its charges.
