Pediatrics billing
Volume game: lots of low-dollar visits where one missed code or modifier wipes out the margin on the visit — and Texas Medicaid quirks dominate the AR.
Texas peds practices live or die by Medicaid. Get TMHP wrong and your AR aging is brutal — get it right and you have a steady stream that pays predictably.
Where revenue leaks
The pediatrics traps we see most
Patterns we run into across Peds practices in Texas. None are obvious from a 30,000-foot view of the practice — they show up only when someone's actually looking at every claim.
Missed immunization administration codes
Every immunization needs both the vaccine code AND the administration code (90460/90461 for under-19, with counseling; 90471–90474 without). Forgetting administration codes loses $20–$30 per shot — across a busy peds panel, that's tens of thousands per year.
Well-visit + sick-visit same day
When a child shows up for a well visit and gets diagnosed with an ear infection, both can be billed with modifier 25. Most peds practices either pick one or get the modifier 25 denied because documentation doesn't separate them clearly.
TMHP enrollment lapses
Texas Medicaid (TMHP) revalidates every 5 years and is unforgiving about missing the deadline. A lapsed enrollment means every Medicaid visit gets denied until re-enrolled — a 60-90 day cash-flow hole.
Developmental screening codes ignored
96110 (developmental screening) pays $10–$15 per screening and is reimbursable separately from the well-child visit. AAP recommends 9, 18, and 30-month screenings — that's $30–$45 of legitimate billable revenue per child per year that often goes uncoded.
Coding focus
Where our coders specialize
- Well-child visits (99381–99385 new, 99391–99395 established)
- Vaccine + administration codes (90460/90461 with counseling; CVX/CPT vaccine code per dose)
- Sick visit add-ons with modifier 25
- Developmental screening (96110, 96112, 96113)
- Behavioral assessments (96127)
- Hearing/vision screening (92551/92552, 99173)
Texas payer notes
Local rules we navigate every day
- Texas Medicaid via TMHP — strict on Texas Health Steps (THSteps) checklist completeness for well-child claims
- STAR/STAR Kids/STAR Health managed Medicaid plans (Superior, Amerigroup, Cook Children's, Driscoll, Texas Children's) each have slightly different prior-auth rules for specialty referrals
- BCBS TX HMO requires PCP designation matched correctly or claims deny
- VFC (Vaccines for Children) program tracking — must distinguish state-supplied vs. private-purchased vaccine inventory
Peds KPIs we track
Specialty-specific benchmarks
We tailor reporting per specialty — these are the metrics that matter most for pediatrics.
99%+
Immunization admin code capture rate
95%+
Modifier 25 well+sick acceptance
<5%
TMHP claim denial rate
What's your pediatrics practice leaking?
Get a free Revenue Leakage Analysis customized to Peds billing patterns. Three specific leaks at your practice, dollar amounts, and exactly how to fix them. 3 business days. No sales pitch.
Other specialties we serve