Age-specific coding errors in pediatric billing cost healthcare practices significant revenue annually. According to the American Academy of Pediatrics, the average claim denial rate for pediatricians reaches 13%, substantially exceeding the healthcare industry’s overall denial rate of 5-10%. A considerable portion of denials stems from age-inappropriate code selection and inadequate documentation.
The Centers for Medicare & Medicaid Services enforces strict age-based coding requirements across pediatric CPT code categories. This guide examines the pediatric CPT codes list, organized by developmental age categories, for accurate billing.
Pediatric CPT Codes by Age Group: The Four Essential Categories
The American Medical Association structures the CPT code pediatric billing into four developmental age categories. The CPT code pediatric framework ensures accurate representation of physician work across developmental stages. Pediatric CPT code selection requires precise age verification on the date of service.
The Four Age Categories:
- Infant (birth to under 1 year)
- Early Childhood (1-4 years)
- Late Childhood (5-11 years)
- Adolescent (12-17 years)
These categories apply across all CPT codes for pediatrics. Understanding CPT codes for pediatrics by age category prevents common billing errors.
Pediatric CPT Codes for Newborn Care Services
Hospital care for neonates utilizes specialized codes. The CPT code newborn exam structure differs from office-based care. Providers must understand both the CPT code pediatric newborn categories and office-visit codes.
| CPT Code | Description | Session Time |
| 99460 | Initial hospital/birthing center care per day for a normal newborn, first day of life | 20-30 minutes |
| 99461 | Initial care for a normal newborn outside the hospital setting | 20-30 minutes |
| 99462 | Subsequent hospital care per day for a normal newborn | 15-20 minutes |
| 99463 | Same-day admission and discharge for a normal newborn | 20-30 minutes |
The 99460 CPT code description covers initial hospital care for evaluation of a normal newborn infant. This CPT code newborn exam includes examination of vital signs and reflexes. Understanding the 99460 CPT code description prevents billing errors.
Pediatric CPT Codes for E/M Visits
Evaluation and management visits for sick children utilize standard E/M codes. The CPT code pediatric E/M structure applies uniformly across age groups. Proper selection from CPT codes for pediatrics E/M categories ensures accurate reimbursement.
| CPT Code | Description | Time | Complexity |
| 99202-99204 | New patient office visits | 15-59 min | Straightforward to moderate |
| 99212-99214 | Established patient office visits | 10-39 min | Straightforward to moderate |
Pediatric CPT Codes for Preventative Care
Office-based well-child visits follow the CPT code for pediatric well visit structure with distinct codes for each age category. The pediatric CPT codes list includes specific preventive codes. The selection of the appropriate CPT code for a pediatric well visit requires verification of patient age. The CPT code pediatric preventive care framework spans all four age categories.
Understanding CPT codes for pediatric preventive services ensures proper billing. Providers must distinguish between the CPT code for pediatric well visit office encounters, the CPT code newborn exam hospital services, and the CPT code for newborn well visit outpatient appointments.
| CPT Code | Description | Age Range | Session Time |
| 99381 | Initial comprehensive preventive medicine, new patient | Infant (<1 year) | 30-40 minutes |
| 99391 | Periodic preventive medicine, established patient | Infant (<1 year) | 30-40 minutes |
| 99382 | Initial comprehensive preventive medicine, new patient | Early childhood (1-4) | 30-40 minutes |
| 99392 | Periodic preventive medicine, established patient | Early childhood (1-4) | 30-40 minutes |
| 99383 | Initial comprehensive preventive medicine, new patient | Late childhood (5-11) | 30-40 minutes |
| 99393 | Periodic preventive medicine, established patient | Late childhood (5-11) | 30-40 minutes |
| 99384 | Initial comprehensive preventive medicine, new patient | Adolescent (12-17) | 30-40 minutes |
| 99394 | Periodic preventive medicine, established patient | Adolescent (12-17) | 30-40 minutes |
The 99393 CPT code description encompasses comprehensive health supervision, including screening and counseling. The CPT code for newborn well visit schedule includes visits at 2, 4, 6, 9, and 12 months. Each CPT code for pediatric well visit incorporates age-appropriate developmental screening.
Pediatric CPT Codes for Immunization
Vaccine administration uses component-based coding for patients under 18 years. The CPT code pediatric immunization billing structure requires counting individual vaccine components. Accurate application of CPT codes for pediatric immunization services prevents underbilling.
| CPT Code | Description | Session Time |
| 90460 | Immunization administration first/only component with counseling, under 18 years | 5-10 minutes |
| 90461 | Each additional vaccine component with counseling, under 18 years | Included |
| 90471 | Immunization administration first vaccine without counseling | 3-5 minutes |
| 90472 | Each additional vaccine without counseling | Included |
Common Vaccine Products
| Vaccine | Product Code | Components | Administration Billing | Age |
| MMR | 90707 | 3 | 90460 x1, 90461 x2 | 12-15 months |
| DTaP | 90700 | 3 | 90460 x1, 90461 x2 | 2, 4, 6, 15-18 months |
| Hepatitis A | 90633 | 1 | 90460 x1 | 12-23 months |
| HPV | 90651 | 1 | 90460 x1 | 11-12 years |
| Tdap | 90715 | 3 | 90460 x1, 90461 x2 | 11-12 years |
Pediatric CPT Codes for Counseling, Preventive Medicine & Risk Reduction
Time-based counseling codes apply when provided separately from preventive visits.
| CPT Code | Description | Duration |
| 99401-99404 | Individual preventive medicine counseling | 15-60 minutes |
| 99411-99412 | Group preventive medicine counseling | 30-60 minutes |
Pediatric CPT Codes for Chronic Care Management
Chronic care management applies when patients have two or more chronic conditions. The CPT code pediatric chronic care structure supports ongoing management of complex conditions. Proper use of CPT codes for pediatric chronic care management generates additional revenue.
| CPT Code | Description | Duration |
| 99491 | Chronic care management services, first 30 minutes per month | 30 minutes |
| 99437 | Each additional 30 minutes | 30 minutes |
| 99487 | Complex chronic care management, first 60 minutes | 60 minutes |
| 99489 | Each additional 30 minutes of complex | 30 minutes |
Pediatric CPT Codes for Principal Care Management
Principal Care Management addresses patients with one complex chronic condition. The CPT code pediatric principal care management structure fills the gap for single-condition patients. Understanding CPT codes for pediatric principal care management enables proper billing.
| CPT Code | Description | Duration |
| 99424 | Principal care management, physician, first 30 minutes | 30 minutes |
| 99425 | Each additional 30 minutes, the physician | 30 minutes |
| 99426 | Principal care management, clinical staff, first 30 minutes | 30 minutes |
| 99427 | Each additional 30 minutes, clinical staff | 30 minutes |
Prevent Revenue Loss with Expert Pediatric Billing Support
Age-transition errors at 18, incorrect vaccine component counts, and missed preventive service billing cost pediatric practices thousands monthly. These aren’t random mistakes—they’re systematic gaps that repeat until someone catches them.
Nexus io specializes in pediatric billing services built around age-based CPT requirements. Our certified coders know the difference between 99384 and 99385, understand three-component MMR billing, and catch well-child visit documentation gaps before claims leave your practice.
We provide eligibility verification, charge capture optimization, denial management, and compliance monitoring designed specifically for pediatric revenue cycles.
Our clients achieve clean claim rates exceeding 94% while reducing accounts receivable days and administrative burden. Ready to improve your pediatric billing accuracy? Schedule a free consultation to identify coding gaps costing your practice revenue.
