Pediatric Coding Alert

Strengthen your screening and immunization coding skills before the rush!

This season brings a familiar wave of well-child visits, sports physicals, screenings, and immunization questions — and with them, plenty of coding details that can trip up even experienced pediatric coders.

From knowing when to report screening and testing services separately to understanding what to do when a child cannot complete a vision screen or a family refuses vaccination, these common scenarios require careful attention to guidelines, payer rules, and documentation.

Study these FAQs to sharpen your pediatric coding skills before the back-to-school-year rush begins.

Question: What is the difference between testing and screening?

Answer: When it comes to understanding the differences between screenings and tests, the distinction can seem unclear. Screening relies on an observer’s report of a child’s abilities, with those observations being documented using a standardized, validated screening tool. Because the results are based on the observer’s perception of the child’s skills, screening is considered subjective. Testing, on the other hand, uses standardized information to directly measure what the patient can do at the time of the evaluation.

Question: Do you need to bill screenings by themselves?

Answer: No, you can bill many screenings with other services. For example, vision screens such as 99173 (Screening test of visual acuity, quantitative, bilateral) and hearing screens such as 92551 (Screening test, pure tone, air only) can be billed together with developmental and behavioral screens such as:

• 96110 (Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument)
• 96112 (Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; first hour)
• +96113 (each additional 30 minutes (List separately in addition to code for primary procedure))
• 96127 (Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/ hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument).

Remember: You can bill screening and testing services with any evaluation and management (E/M) service, including preventive and sick visit encounters, as long as both services are supported by the practitioner’s work and visit notes. According to the American Academy of Pediatrics (AAP) guidance, this may require appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M service or modifier 59 (Distinct procedural service) to the screening or testing code, depending on the payer requirements and the services being performed.

Make note: You’ll report developmental testing using 96112 for the first hour of standardized developmental test administration, interpretation, and report by a physician or other qualified healthcare professional. If the service extends beyond the first hour, you’ll use add-on code +96113 for each additional 30 minutes.

Also, if you bill 96112/+96113 on the same date as an E/M service, make sure the developmental testing work is kept separate. Do not use the time or work involved in administering and interpreting the test to support the E/M level through either time or medical decision making.

For a comprehensive list of standardized screening tools, go to the AAP’s Screening Technical Assistance and Resource (STAR) Center website.  

Question: Should you use modifier 52 or 53 for an incomplete pediatric vision screening if the child is unable to identify letters or remain seated long enough to finish the test?

Answer: No, appending modifier 52 (Reduced services) or modifier 53 (Discontinued procedure) to 99173 or 99174 (Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with remote analysis and report), for example, would not be appropriate in this situation.

Modifier 52 applies when a physician or other qualified healthcare professional elects to partially reduce or eliminate a service or procedure. Modifier 53 would also not apply. Per Appendix A of the CPT^® code book, modifier 52 is used when “a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional.” In this case, the service is not being terminated by pediatrician choice; rather, the child’s inability to recognize letters or remain still made it impossible to complete the screening.

Because the provider could not complete the screening under these circumstances, you generally shouldn’t report the service at all.

Question: What if a patient needs an immunization, but the parent, guardian, or patient refuses to have it administered?

Answer: When immunizations are refused, you’ll look to ICD-10-CM code Z28.- (Immunization not carried out and underimmunization status).

When a patient refuses an immunization for a reason other than the patient’s health or religious/social belief, you have three choices of codes to document the refusal:

• Z28.20 (Immunization not carried out because of patient decision for unspecified reason): Use this code when the patient has not specifically refused the vaccination, but they still did not receive one.
• Z28.21 (Immunization not carried out because of patient refusal): Use this code when the patient has not given a specific reason for the refusal.
• Z28.29 (Immunization not carried out because of patient decision for other reason): Use this code when a reason for the refusal was given, but no other code captures it accurately.

Age matters: Make a note that your application of a Z28.2- code implies the patient is old enough to make their own decision about the immunization. If they are not, you will turn to code Z28.82 (Immunization not carried out because of caregiver refusal) instead.

Even if the encounter does not result in the patient being vaccinated, if your provider provides vaccination safety counseling at the session, you’ll still report Z71.85.

Make note: As of Jan. 1, 2026, three new CPT^® codes gave physicians and other qualified healthcare professionals a way to report immunization counseling and related clinical services when a vaccine is ultimately refused by the caregiver for the child. These standalone, time-based codes address a gap pediatric clinicians have long encountered: Vaccine discussions can require significant time and clinical effort, especially when parents or caregivers are uncertain, reluctant, or decline vaccination altogether.

The new codes are:

• 90482 (Immunization counseling by physician or other qualified health care professional when immunization(s) is not administered by provider on the same date of service; 3 minutes up to 10 minutes)
• 90483 (…greater than 10 minutes up to 20 minutes)
• 90484 (… greater than 20 minutes).

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC