Providing quality care to children requires more than just clinical expertise; it requires accurate reporting, compliance, and proper reimbursement. Pediatric CPT codes are the universal language that connects pediatricians, payers, and families, ensuring that every checkup, vaccination, and counseling session is documented correctly.
Whether you run a busy pediatric practice, manage billing for a healthcare facility, or simply want clarity on how your child’s care is coded, this guide breaks down everything you need to know about pediatric CPT codes in a clear, easy-to-understand way.
What Are Pediatric CPT Codes?
CPT codes or Current Procedural Terminology codes are a standardized set of medical codes maintained by the American Medical Association (AMA). They are used to describe medical, surgical, and diagnostic services provided by healthcare professionals.
In pediatrics, CPT codes serve a crucial role: they accurately report the care provided to infants, children, and adolescents so that payers can process insurance claims correctly. This ensures pediatric practices are reimbursed fairly and patients’ care is properly documented.
Pediatric CPT codes cover a wide range of services, including:
- Evaluation and management (E/M) visits
- Newborn care
- Preventive and well-child checkups
- Immunizations
- Counseling and risk reduction
- Chronic care and principal care management
Correct coding not only ensures compliance but also helps pediatric practices optimize revenue and avoid claim denials.
Pediatric CPT Codes for Evaluation & Management (E/M) Visits
E/M visits are some of the most frequently reported services in pediatric practices. These codes reflect the level of decision-making, time spent with the patient, and whether the patient is new or established.
E/M Codes for New Patients (99202–99205)
When a new patient (0–17 years old) visits a pediatrician, the provider reports CPT codes 99202 through 99205. The selection depends on the complexity of medical decision-making and the time spent during the visit.
| Pediatric CPT Code | Level of Decision-Making | Typical Time |
| 99202 | Straightforward | 15+ minutes |
| 99203 | Low | 30+ minutes |
| 99204 | Moderate | 45+ minutes |
| 99205 | High | 60+ minutes |
These visits are vital for establishing a child’s medical history, conducting exams, and creating care plans for acute or chronic issues.
E/M Codes for Established Patients (99212–99215)
For established patients, pediatricians use CPT codes 99212 through 99215. These codes also rely on the level of decision-making and time spent.
| Pediatric CPT Code | Level of Decision-Making | Typical Time |
| 99212 | Straightforward | 10+ minutes |
| 99213 | Low | 20+ minutes |
| 99214 | Moderate | 30+ minutes |
| 99215 | High | 40+ minutes |
Choosing the correct E/M code ensures practices are reimbursed fairly and prevents overcoding or undercoding, which can lead to compliance risks.
Pediatric CPT Codes for Newborn Care
Each day, thousands of newborns in the U.S. receive care from pediatricians, from initial evaluations to hospital discharge. Proper reporting of these services is essential for reimbursement.
- CPT 99460: Used when a provider performs routine newborn care for a healthy baby in a hospital or birthing facility. Reported once per day until discharge.
- CPT 99461: Used for initial care when a newborn is evaluated and managed outside of the hospital (e.g., in a clinic or home setting).
- CPT 99462 & 99463: Cover subsequent hospital care and discharge services for newborns.
By using these codes accurately, providers ensure every day of newborn care is accounted for, which is critical given the intensive monitoring newborns often require.
Pediatric CPT Codes for Immunizations
Immunization is one of the most common and important pediatric services. Correct coding ensures both the vaccine product and its administration are billed properly.
- CPT 91318: Reports Pfizer COVID-19 vaccine for children aged 6 months–4 years (0.3 mL dose, intramuscular).
- CPT 91321: Reports Moderna COVID-19 vaccine for children aged 6 months–11 years (2.25 mL dose, intramuscular).
- CPT 90380 & 90381: Used for RSV monoclonal antibody immunizations (0.5 mL and 1 mL doses based on weight).
- CPT 90686: Reports preservative-free influenza vaccine, 0.5 mL, administered intramuscularly.
- CPT 90710: Used for the combination vaccine for measles, mumps, rubella, and varicella (MMRV), administered subcutaneously.
Always report both the vaccine product code and the vaccine administration code to receive full reimbursement.
Pediatric CPT Codes for Preventive Care Visits
Preventive care visits, also known as well-child visits, are designed to monitor growth, provide education, and catch potential health issues early. These visits are recommended at regular intervals throughout childhood.
Preventive Care for New Patients
- CPT 99381: Well-baby visit for infants under 1 year old (new patient).
- CPT 99383: Preventive care visit for children aged 5–11 (new patient).
- CPT 99384: Preventive care visit for adolescents aged 12–17 (new patient).
Preventive Care for Established Patients
- CPT 99391: Well-baby visit for infants under 1 year (established patient).
- CPT 99393: Preventive care visit for children aged 5–11 (established patient).
- CPT 99394: Preventive care visit for adolescents aged 12–17 (established patient).
These visits include physical exams, developmental screenings, growth tracking, anticipatory guidance for parents, and recommended immunizations. Correct coding ensures these services are fully reimbursed and supports continuity of care.
Pediatric CPT Codes for Counseling & Risk Reduction
Counseling sessions give providers the opportunity to address lifestyle, behavioral, and social issues that could affect a child’s health.
Individual Counseling (99401–99404)
| Code | Description | Duration |
| 99401 | Individual preventive counseling | ~15 min |
| 99402 | Extended counseling session | ~30 min |
| 99403 | Detailed counseling session | ~45 min |
| 99404 | Comprehensive counseling session | ~60 min |
Topics may include nutrition, physical activity, substance use prevention, mental health, and safe behaviors.
Group Counseling (99411–99412)
| Code | Description | Duration |
| 99411 | Group preventive counseling session | ~30 min |
| 99412 | Extended group session | ~60 min |
Group counseling encourages peer learning and is effective for topics like healthy lifestyle habits and stress management.
Pediatric CPT Codes for Chronic Care Management (CCM)
Chronic care management is crucial for children with long-term conditions like asthma, diabetes, or epilepsy.
- CPT 99491: First 30 minutes of CCM provided personally by the pediatrician.
- CPT 99437: Additional 30 minutes of CCM (billed with 99491).
- CPT 99487: Complex CCM, first 60 minutes (clinical staff under physician supervision).
- CPT 99489: Additional 30 minutes of complex CCM (billed with 99487).
These codes are billed once per calendar month and require thorough documentation of care coordination and medical decision-making.
Pediatric CPT Codes for Principal Care Management (PCM)
Principal Care Management is designed for children with a single high-risk chronic condition requiring focused care.
- CPT 99424: First 30 minutes of PCM personally provided by physician.
- CPT 99425: Additional 30 minutes of PCM by physician (add-on).
- CPT 99426: First 30 minutes of PCM by clinical staff, supervised.
- CPT 99427: Additional 30 minutes of PCM by supervised staff (add-on).
PCM is ideal for children needing targeted care management for conditions like severe asthma or post-surgical recovery.
Best Practices for Pediatric CPT Code Reporting
1. Document Everything: Detailed notes help support the selected code level and reduce audit risk.
2. Code by Time and Complexity: Select the correct E/M code based on time spent and level of medical decision-making.
3. Use Add-On Codes Properly: For CCM and PCM services, pair add-on codes with the primary codes to reflect the full duration of care.
4. Verify Payer Guidelines: Some payers have specific rules for modifiers or bundled services.
5. Train Your Staff: Regular coding education keeps your team compliant and minimizes denials.
Common Coding Mistakes to Avoid
- Undercoding or Overcoding E/M Visits: Leads to revenue loss or compliance issues.
- Missing Administration Codes: When billing for vaccines, always report both product and administration codes.
- Incorrect Time Reporting: Ensure time-based codes reflect actual minutes spent face-to-face or coordinating care.
- Failing to Bill for Counseling: Providers often overlook reporting counseling sessions, which results in lost revenue.
Summary
Accurate pediatric CPT coding is more than a billing task; it is an essential part of delivering high-quality care. From newborn evaluations to adolescent counseling and chronic care management, every service has a specific CPT code that ensures providers are reimbursed fairly and patients’ health journeys are documented correctly.
By following coding best practices, verifying payer rules, and staying updated with the latest AMA CPT guidelines, pediatric practices can protect their revenue cycle and focus on what matters most: helping children grow healthy and thrive.
