The denial pattern
Many pediatric patients are covered by Medicaid, CHIP or Medicaid managed care, and redetermination can move a family from one plan to another between visits. The family rarely knows; the claim comes back CO-27 — coverage terminated.
How we prevent it
- Eligibility re-verified before every visit, including well-child checks
- Managed-care plan assignment confirmed, not assumed
- State Medicaid and managed-care enrollment for every provider
- Vaccine administration and well-visit coding reviewed
- Rebilling to the correct plan inside the filing deadline
Well-child visits and vaccines
Well-child visits follow the preventive codes for the child's age, often alongside screenings and vaccines that are billed separately. Each vaccine has two parts: the product code and an administration code (90460 and 90461 when counselling is provided to patients under 19, or 90471–90474 otherwise). Vaccines supplied free through the Vaccines for Children program are billed for administration only. Missing an administration code, or billing a VFC vaccine as purchased stock, is a common and quiet leak.
Sick visits on the same day
When a child is seen for a problem during a well visit, the problem-oriented visit can be billed with modifier 25 — if the note documents it separately. We code from the documentation and send queries back when it doesn't.