The Ultimate Pediatrician’s Cheat Sheet for CPT Codes

As a pediatrician you need to get very accurate when it comes to CPT coding. From capturing the right code for a well-child visit to ensuring accurate billing for immunizations and vaccine administration, every detail matters.

Pediatric coding isn’t just about the service provided; it’s about documenting the complexity of care, including developmental milestones, age-specific procedures, and even the delicate nuances of administering combination vaccines.

For instance, are you confidently using the correct code for a 15-minute consultation versus a 30-minute one? Or do you know how to appropriately document multiple vaccines administered in a single visit? These specifics can mean the difference between a seamless claim approval and unnecessary denials.

So what if all the details are gathered in a single guide? Will this make your life easy? Absolutely! So let's dive into the world of pediatric cpt codes.

Pediatrician’s Evaluation & Management CPT Codes 

Pediatricians often encounter children with acute illnesses, follow-up needs, or chronic conditions requiring management. Accurate coding depends on the patient’s status (new vs. established) and the complexity of the visit.

99202–99205: New Patient

These codes are used when a child is seen for the first time for a non-preventive service. The level depends on the medical decision-making (MDM) or time spent:

99202: Straightforward MDM, ~15–29 minutes.

99203: Low MDM, ~30–44 minutes.

99204: Moderate MDM, ~45–59 minutes.

99205: High MDM, ~60–74 minutes.

99212–99215: Established Patient

For patients returning to the practice for non-preventive services, these codes reflect the level of MDM or time:

• 99212: Straightforward MDM, ~10–19 minutes.

• 99213: Low MDM, ~20–29 minutes.

• 99214: Moderate MDM, ~30–39 minutes.

• 99215: High MDM, ~40–54 minutes.

Emergency Department Visits

Pediatricians providing care in emergency settings need to use specific codes for ED visits based on complexity.

CPT Code (99281–99285)

99281: Minor problems requiring minimal MDM.

99282: Low MDM for issues such as mild asthma or simple injuries.

99283: Moderate MDM, such as for persistent high fever or moderate dehydration.

99284: High MDM for conditions like severe respiratory distress.

99285: Critical cases with immediate threats to life, such as sepsis or severe trauma.

Consultation

When a pediatrician is asked to evaluate a patient and provide recommendations for a specific problem, consultation codes should be used.

Outpatient Consultation (99242–99245)

99242: Straightforward MDM, ~At least 20 Minutes
Appropriate for cases requiring minimal complexity, such as dietary consultations or addressing mild developmental concerns.

99243: Low MDM, ~At least 30 Minutes

For conditions requiring more detailed analysis, such as evaluating mild asthma symptoms or non-severe allergic reactions.

99244: Moderate MDM, ~At least 40 Minutes

Commonly used for moderately complex issues like recurrent febrile episodes, moderate asthma exacerbations, or more involved developmental concerns.

99245: High MDM, ~ At least 55 minutes

Reserved for highly complex cases, such as managing severe congenital conditions, in-depth genetic consultations

Critical Care Services

For life-threatening conditions requiring immediate and continuous attention, pediatric critical care codes should be used.

CPT 99291–99292:

99291: First 30–74 minutes of critical care.

99292: Each additional 30 minutes.

Common scenarios include sepsis management, severe respiratory failure, or multisystem trauma.

Vaccine Administration

These CPT codes are used for documenting the administration of vaccines. They account for the work involved in counseling the patient/family, administering the vaccine, and observing the patient afterward.

Single Vaccine Administration

90460: Administration of the first or only vaccine component, with counseling provided by the physician or qualified healthcare professional.

90461: Each additional vaccine/toxoid component, with counseling.

Non-Counseling Vaccine Administration

90471: Administration of one vaccine (single or combination), without counseling.

90472: Each additional vaccine, without counseling.

Intranasal or Oral Administration

90473: Single vaccine administration by intranasal or oral route, without counseling.

90474: Each additional vaccine administered by intranasal or oral route, without counseling.

 Vaccine Product Codes

These CPT codes represent the vaccine product itself, which must be billed separately. Specific vaccine codes are based on the type of vaccine and its manufacturer. Some of the most commonly used pediatric vaccine product codes include:

Combination Vaccines

• 90696: DTaP-IPV (Kinrix).

• 90698: DTaP-Hib-IPV (Pentacel).

• 90723: DTaP-Hep B-IPV (Pediarix).

Routine Childhood Vaccines

• 90633: Hepatitis A (2-dose series).

• 90647: Haemophilus influenzae type b (Hib).

• 90707: MMR (Measles, Mumps, Rubella).

• 90680: Rotavirus (oral, 3-dose series).

• 90713: Polio (IPV).

• 90716: Varicella (chickenpox).

Influenza Vaccines

• 90686: Quadrivalent flu vaccine, preservative-free (ages 6 months and older).

• 90672: Intranasal live attenuated influenza vaccine (ages 2 years and older).

Human Papillomavirus (HPV) Vaccine

• 90651: HPV vaccine (9-valent) for ages 9–45.

Final Words

Accurate pediatric CPT coding is essential for ensuring timely reimbursements and maintaining the financial health of your practice. By having information about the codes for Evaluation & Management, immunizations, and vaccinations, pediatricians can focus on what their core priorities are, that’s taking care of their patients. 

Let HMS USA LLC take the stress out of pediatric billing with our dedicated services. We’ll handle the details while you focus on your patients.