Pediatric practices with 40%+ Medicaid payer mix leave an average of $52,000 a year on the table from EPSDT-mandated screenings alone — 73% of practices omit at least one billable screening per well-child visit.
Common Billing Challenges
These are the six billing failure points we see most often in pediatric practices — and the ones our team resolves systematically from day one.
Billing a well-child visit plus a same-day sick visit without modifier 25 gets the sick visit automatically bundled and denied — correctly applying it recovers $41,000–$67,000 per physician per year.
Billing the vaccine product code on VFC-eligible stock isn't just a missed opportunity — it's a compliance violation. Only the administration fee is billable when using VFC vaccines.
From initial rating scales (96127) through medication management E/M levels to Chronic Care Management for co-occurring conditions — most practices only capture the first step of the ADHD billing cycle.
Standardized screening at 9-, 18-, and 30-month visits plus autism screening at 18 and 24 months are separately billable from the well-child visit — and frequently left off the claim entirely.
EPSDT requires covering all medically necessary services for children under 21, but same-day billing limits, screening codes, and reimbursement rates vary significantly by state — a 50-state compliance puzzle general billers rarely get right.
Using the wrong Place of Service code (02, 10, or 03 for school-based telehealth) or the wrong modifier (95 vs. GT depending on payer) causes denials that are entirely avoidable with correct payer-specific setup.
Key Procedure Codes
Our coders hold specialty-specific credentials and train continuously on the codes that drive the most revenue — and the most denials — in pediatrics.
| CPT Code | Description | Common Issue |
|---|---|---|
| 99391–99395 | Established patient preventive visit, by age | Age-based, not complexity-based selection |
| 90460/90461 | Vaccine admin with counseling, plus each add'l component | Product code wrongly billed with VFC vaccines |
| 96110 | Developmental screening with scoring | Required at 9/18/30 months, often omitted |
| 96127 | Brief behavioral/emotional assessment | Used for ADHD scales and autism screening |
| 99490 | Chronic Care Management, first 20 min/month | Massively under-billed for ADHD + comorbidity |
| Modifier 25 | Significant, separate E/M same day | Missing documentation separation triggers denial |
Why Rcmaxis
We're not a generalist billing service that added a specialty module. Our team is built around specialty-specific expertise.
Every coder on your account holds the specialty coding credential relevant to pediatrics — not a generic CPC only.
Significantly above the 9.8% industry denial rate for this specialty. Fewer rejections means faster payment and less write-off risk.
Full EHR integration, payer enrollment verification, and charge capture setup in 2 weeks — with zero disruption to your clinical schedule.
One point of contact who knows your practice, your payers, and your billing history — available for weekly calls and monthly performance reviews.
Month-to-month engagement. We earn your business every month by improving your collections — not by locking you in.
Live visibility into your collections, denial rate, aging AR, and payer performance — updated daily, reviewed monthly with your account team.
Straight answers to what practices usually ask before they switch.
Free revenue assessment for qualified practices. We audit your last 90 days of claims, identify every revenue leak, and show you a clear path to better collections — at no cost.