# Question regarding reimbursement



## heisner33 (Mar 23, 2011)

Does anyone else ever run into situations where a lower code actually reimburses more money than the higher code?? Is it ok to kind of down code for the financial difference? For example, our office bills the new vaccine administration codes of 90460 & 90461 and for a couple payers unless there are 2 or more single component vaccines or 1 with multiple components it is actually financially beneficial to bill 90471 & 90472 in the place of 90460.  Since we are meeting guidelines of 90471 & 90472 is it ok to bill those over 90460 and 90461 even when counseling was performed by Dr. with patient or patient family??


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## magnolia1 (Mar 23, 2011)

WOW........

I had to read this a few times to make sure that I was really seeing what I was seeing.....

I do not do the same type of coding that you do........(I code Hospital Ambulatory Surgery), 
however I will respond this way.......

Downcoding is considered just as *fraudulent* as upcoding..........


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## btadlock1 (Mar 23, 2011)

If you're billing the components correctly, you should be getting a higher reimbursement than the old system. It would be inappropriate and considered illegal to knowingly bill the wrong code to receive higher reimbursement. Just to go over the differences in the code sets, though...

90471-90474 are based on the # of physical administrations that you give, not how many vaccines you're giving. So, for example, if you were giving an MMR, and DTaP, and an influenza vaccine, you'd bill three administrations: 90471, 90472, 90472.

Now, with the pediatric vaccine codes 90460 & 90461, you bill for the administration of each component of the combination vaccines, regardless of how many shots are given. Each vaccine product with a CPT code is reported with 90460, and vaccines with multiple components (combination vaccines) also get 1x 90461 for each additional vaccine product contained in the combination. So, sticking with the example from above, the admin codes would be billed like this:

[MMR CPT]
90460 (Measles)
90461 (Mumps)
90461 (Rubella)
[DTaP]
90460 (Diptheria)
90461 (Tetanus)
90461 (Pertussis)
[Influenza]
90460 (Influenza)
(I don't have my book with me, and I don't have those vaccine codes memorized). Insurers require the codes to be sequenced in this manner, to easily distinguish which admins go with which vaccines. Many are still inappropriately denying correctly billed codes as duplicates, but they should reprocess the denials, when asked. You are paid less for the 90461's because the only represent a portion of a single administration, and you've already been paid for the bulk of the work in 90460. Hope that helps!


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## heisner33 (Mar 29, 2011)

*Let me clarify!*

Our office takes great pride in counseling for vaccines with patients and parents.  There are very few times that we give vaccines without counseling from a provider even before the new administration rules were in effect.  

We just happen to have a single payer that pays $10 for every 90460 and $5 for every 90461. This same payer pays much more for 90471 and 90472. If you have a vaccine with only one component it pays to not do the counseling on the date the vaccine is given.  It pays to bill the 90471. What we were wondering is if other offices have found this same thing to be true in their practice and how do they handle it? 

We have been contemplating providing the counseling in say a 9 month well child exam and then when the vaccines are due at the 12 month visit just having them come in and having a nurse perform the vaccines and be able to bill 90471.  Technically I don't feel there is anything fraudulent on doing so because our providers take the extra time during the previous well child exam to provide the counseling for the childs upcoming vaccines to be given.  So it's not really downcoding as the day they are given 90471 is the best code selection and it's not giving the patient any different level of care than we stand by as an office but it does allow for more payment from the carrier for the same amount of work.


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## btadlock1 (Mar 30, 2011)

heisner33 said:


> Our office takes great pride in counseling for vaccines with patients and parents.  There are very few times that we give vaccines without counseling from a provider even before the new administration rules were in effect.
> 
> We just happen to have a single payer that pays $10 for every 90460 and $5 for every 90461. This same payer pays much more for 90471 and 90472. If you have a vaccine with only one component it pays to not do the counseling on the date the vaccine is given.  It pays to bill the 90471. What we were wondering is if other offices have found this same thing to be true in their practice and how do they handle it?
> 
> We have been contemplating providing the counseling in say a 9 month well child exam and then when the vaccines are due at the 12 month visit just having them come in and having a nurse perform the vaccines and be able to bill 90471.  Technically I don't feel there is anything fraudulent on doing so because our providers take the extra time during the previous well child exam to provide the counseling for the childs upcoming vaccines to be given.  So it's not really downcoding as the day they are given 90471 is the best code selection and it's not giving the patient any different level of care than we stand by as an office but it does allow for more payment from the carrier for the same amount of work.



It sounds like you've got a contracting issue, and you're not being paid correctly. You should talk to your provider relations rep at the insurer, and verify that those amounts are correct. I believe that's less than Medicaid allows for those services.


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