Pediatricians serve a critical role in healthcare — providing care to infants, children, and adolescents. But while their clinical focus is on growth and development, managing the billing for pediatric services is anything but child’s play.

From well-child visits to immunizations, growth tracking to chronic illness management, pediatric practices handle a high volume of visits, frequent insurance plan changes, and complex payer guidelines. At Progressive RCM, we offer specialized pediatrics billing services that streamline operations, improve collections, and support your mission of caring for kids.

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What Makes Pediatrics Billing Unique?

Pediatrics billing differs from adult medicine in several key ways:

1. Age-Specific Coding

CPT and ICD-10 codes are often specific to age or developmental stage. Newborn care, adolescent counseling, and immunization coding all vary.

2. Frequent Preventive Visits

Pediatric patients often visit more frequently than adults — requiring proper billing for well-visits, screenings, and age-based exams.

3. Immunization Management

Vaccinations come with product codes and separate administration codes, requiring accurate bundling to avoid revenue loss.

4. Parent/Guardian Coverage Variability

Changes in coverage, Medicaid eligibility, or split insurance responsibilities can lead to denied or delayed claims if not handled properly.

5. Modifier Usage

Using correct modifiers (e.g., -25, -59, -SL) is essential when multiple services are performed in the same visit, especially with sick and well visits on the same day.

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Progressive RCM’s Pediatric Billing Services

At Progressive RCM, we help pediatricians maximize their reimbursements, avoid coding errors, and keep cash flow healthy.

✅ Age-Based Coding Expertise

Our certified coders understand the nuances of pediatrics, including developmental screenings, preventive care, and acute visits. We accurately use:

• ICD-10 codes for age-specific diagnoses

• CPT codes for well-child checks, screenings, and sick visits

• Immunization codes (with proper administration)

✅ Vaccine & Immunization Billing

Vaccines require precision — each has a code for the product and another for the administration. We bill correctly using VFC (Vaccines for Children) modifiers, track batch numbers, and verify payer coverage.

✅ Well & Sick Visit Billing on the Same Day

We correctly apply modifier -25 when billing for a preventive visit and a problem-focused visit during the same encounter — a common scenario in pediatrics.

✅ Claims Submission & Tracking

We submit clean claims within 24–48 hours, verify clearinghouse acceptance, and follow up on denials or delays.

✅ Insurance Verification & Eligibility Checks

Before each visit, we verify insurance status, plan benefits, and copays — including Medicaid and CHIP programs.

✅ Denial Management & Appeals

We analyze denial trends, correct errors quickly, and resubmit or appeal with the necessary documentation to secure payment.

✅ Patient Billing & Communication

We send clear, family-friendly statements and offer flexible payment options — improving patient satisfaction and reducing unpaid balances.

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Common Pediatric Services We Bill For

• Newborn care & hospital follow-ups

• Well-child checks (per AAP schedule)

• Immunizations and vaccine administration

• Developmental screenings (ASQ, MCHAT)

• Hearing & vision screenings

• ADHD/behavioral evaluations

• Asthma management

• Acute sick visits

• Sports physicals

• Nutrition and weight management counseling

• COVID-19 and flu testing

Each service has specific coding and documentation requirements. We ensure no revenue is left unclaimed.

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Our Pediatric Billing Workflow

1. Insurance Eligibility Verification
   We confirm insurance coverage and eligibility before every visit, especially important with pediatric Medicaid plans.

2. Accurate Coding and Charge Entry
   Proper CPT/ICD-10 coding based on age, service type, and documentation.

3. Claim Submission
   Electronic submission of clean claims to all major payers with correct NPI, taxonomy, and place of service.

4. Payment Posting & Reconciliation
   Posting of payer and patient payments daily, followed by contract-based reconciliation and underpayment detection.

5. AR Follow-Up
   Persistent follow-up on unpaid claims or underpaid services until resolution.

6. Reporting & Analytics
   Monthly performance metrics, denial trends, and patient aging reports provided for transparency and practice improvement.

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Why Choose Progressive RCM for Pediatrics Billing?

✅ Pediatric-Specific Billing Experts
Our team is trained specifically in the complexities of children’s healthcare coding and billing.

✅ Vaccine Billing Knowledge
We manage product + administration codes and VFC program billing with full compliance.

✅ Modifier and Same-Day Visit Experts
Avoid missed revenue with accurate use of modifiers when billing multiple services in one visit.

✅ Medicaid & CHIP Program Familiarity
We handle state-specific rules for Medicaid and Children’s Health Insurance Programs with precision.

✅ EHR/EMR Compatibility
We integrate with pediatric-friendly platforms like Office Practicum, PCC, AthenaHealth, eClinicalWorks, and more.

✅ Family-Focused Communication
Our patient billing is transparent, gentle, and customized for family-friendly practices.

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Key Metrics We Track

• Clean Claim Submission Rate

• First Pass Resolution Rate

• Vaccine Reimbursement Accuracy

• Denial Rate by Service Type

• Net Collection Ratio

• Days in Accounts Receivable (AR)

• Copay Collection Rate

Our goal is to maximize your revenue while minimizing errors and time spent on billing.

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Final Thoughts

Pediatric billing comes with its own set of rules, modifiers, and documentation needs. From tracking vaccine batches to billing well-child visits alongside acute concerns, a pediatric billing partner must be thorough, fast, and specialized.

At Progressive RCM, we bring unmatched expertise in pediatrics billing — helping your practice grow while ensuring every visit is reimbursed correctly.