Comprehensive Pediatric CPT Code Guide for Healthcare Providers
Navigating pediatric CPT codes can be complex, but accurate coding ensures compliance and maximizes reimbursements. This guide includes essential codes for well-child visits, vaccines, procedures, and specialty care.
What Are Pediatric CPT Code Fundamentals?
The appropriate use of CPT codes is one of the most significant elements of pediatric billing. By classifying the services provided to pediatric patients, these codes assist in making sure that each unique service is appropriately recorded for billing purposes. Because pediatric patients have different healthcare demands than adult patients, pediatric CPT codes are different.
Top 10 Pediatric CPT Codes
- 99391: Periodic well-child exam (established patient, ages 1–4).
- 99394: Preventive visit (established patient, ages 5–11).
- 99392: Sick visit (established patient, problem-focused).
- 90460: Vaccine administration (pediatric, per component).
- 90748: Engerix-B (Hep-B pediatric vaccine).
- 90744: Havrix (Hep-A pediatric vaccine).
- 90675: Vaqta (Hep-A pediatric vaccine).
- 54150: Circumcision (pediatric, simple).
- 76604: Pediatric echocardiogram (echo).
- 62270: Lumbar puncture (diagnostic, pediatric).
Well-Child & Sick Visit Codes
- Preventive Visits:
- 99391: Ages 1–4 (established patient).
- 99394: Ages 5–11 (established patient).
- 99381–99385: New patients (age-specific).
- Sick Visits:
- 99212–99215: Office visits (problem severity-based).
- 99202–99205: New patient sick visits.
Vaccine-Specific Codes
Vaccine                         | CPT Code |
Engerix-B (Hep-B) | 90748 |
Havrix (Hep-A) | 90744 |
Vaqta (Hep-A) | 90675 |
Administration | 90460/90461 |
Common Pediatric Procedure Codes
Circumcision:
- 54150 (simple) vs. 54160 (surgical).
- Appendectomy:Â 44950Â (laparoscopic, pediatric).
- Lead Blood Test:Â 83655Â (capillary or venous).
- Hearing Screening:Â 92551Â (automated).
- Sleep Study:Â 95810Â (pediatric Polysomnography).
- Spine Ultrasound:Â 76800Â (neonatal spine).
Specialty-Service Codes
- Gastroenteritis Education:Â 98960Â (individual, 30 mins).
- Wheelchair Fitting:Â 97755Â (adaptive management).
- Pediatric Echo:Â 93303Â (complete echocardiogram).
- Pain Management:Â G0439Â (behavioral screening).
Key Coding Guidelines
- Age Limits: Confirm patient age (e.g., 99394 applies only to ages 5–11).
- Vaccine Bundling: Pair administration codes (90460) with vaccine-specific codes (e.g., 90748).
- Documentation: For sick visits, link symptoms (e.g., fever, dehydration) to codes like 99213.
Accurate coding of pediatric procedures is critical for optimizing reimbursement and preventing claim denials. Healthcare providers must stay updated on coding changes, guidelines, and documentation requirements to ensure accurate coding and maximum reimbursement for services provided.
What’s the age limit for CPT 99394?
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1. What’s the age limit for CPT 99394?
5–11 years (established patients).
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2. How to code a pediatric wheelchair fitting?
Use 97755 + KX modifier if medical necessity is documented.
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3. What CPT code covers Hip-B for adolescents?
90739Â (Hip-B adolescent/adult dose).
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4. What is the CPT Code for Pediatric Patients?
There is no single CPT code for "pediatric patients"—codes depend on the type of service provided:
- Preventive Visits: Use 99381-99394 (age-based well-child exams, e.g., 99391 for 5–11 years).
- Sick Visits: Use 99202-99215 (office/outpatient E/M codes based on medical decision-making or time).
- Vaccines: Pair with 90460-90461 (counseling + administration).
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5. What Age is CPT Code 99395 for?
CPT 99395 is not for pediatric patients. It applies to adults aged 18–39 years for a periodic preventive medicine reevaluation.
- Pediatric Codes: Use 99381–99394 instead (e.g., 99392 for 12–17 years).
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6. What is the ICD-10 Code for a Pediatric Visit?
Use Z00.121 (routine child health exam with abnormal findings) or Z00.129 (without abnormal findings).
- For Sick Visits: Code the diagnosis (e.g., J06.9 for acute URI).
- Newborns: Use Z00.110-Z00.111 (initial newborn exams).
