# 90460 and 90461 denials



## cgneff72 (Mar 28, 2011)

We are getting several denials for the new vaccine admin codes, 90460.  We are billing them out on separate lines (not using multiple units) but they are being denied as duplicates.  I read somewhere that the admin codes need to be "lumped" with their respective vaccine codes on a single claim form.  Sounds easy enough, except the billing software that we use re-orders our codes from most expensive to least.  The only way to ensure the "lumping" of codes is to send my claims paper!  Crazy!!  Any suggestions?

Also, is it true that some payers want the 90460 billed on separate lines, but others will accept it with multiple units?  

Sounds like this has become more trouble than it is worth!!


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## btadlock1 (Mar 28, 2011)

cgneff72 said:


> We are getting several denials for the new vaccine admin codes, 90460.  We are billing them out on separate lines (not using multiple units) but they are being denied as duplicates.  I read somewhere that the admin codes need to be "lumped" with their respective vaccine codes on a single claim form.  Sounds easy enough, except the billing software that we use re-orders our codes from most expensive to least.  The only way to ensure the "lumping" of codes is to send my claims paper!  Crazy!!  Any suggestions?
> 
> Also, is it true that some payers want the 90460 billed on separate lines, but others will accept it with multiple units?
> 
> Sounds like this has become more trouble than it is worth!!



Here's the breakdown...BCBS and Aetna have just announced that they want it done differently than everyone else - all of the payers are still getting their systems used to the new code sets, so denials are common, even when you're doing everything right...
What's different about BCBS and Aetna, is now they don't care about separating out the different 90460's and 90461's by individual vaccine component products – they want them *all* lumped together. 

Most payers want it done this way:
90698
90460x1
90461x4
90707
90460x1
90461x2
90669
90460x1

But BCBS and Aetna want it like this now:
90460x3
90461x7
90698
90707
90669

Hope that made sense!


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## dcousar (Oct 10, 2011)

*Medicaid denials for 90460*

It has been brought to my attention that medicaid is no longer paying the code 90460 as of Sept. 1,2011. This was told to me today by one of the manage care companies and I wanted to know if anyone has heard this same responce also..

Thanks, Dorothy


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## calexander1265 (Nov 2, 2011)

In North Carolina Medicaid will not pay for the 90460 or 90461


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## btadlock1 (Nov 2, 2011)

Ours pays it (TX), but they make it as difficult as possible, and the reiumbursement is pathetic. Will they allow you to bill the admins any other way (like 90471-90474)? - That's the only thing the provider gets paid for on state vaccines! Surely they wouldn't completely cut reimbursement for a core service, without giving you an alternative...

Check with your state's medical group associations (Ours is Texas Medical Association, for example - every state's got them...) to see if they've got any recommendations, (or if not) to see if they're doing anything to fight the legislation, on behalf of your state's providers. A lot of times, they'll start petitions and stuff, and they have a better chance of getting things done than a handful of individual, angry doctors.


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## kbarron (Nov 10, 2011)

How can you bill components of the vaccine when CPT clearly states "it is inappropirate to code each component of a combination vaccine separatey". In NH Medicaid has us bill 90460 for first admin and 90460 w/modifier U1 for each aditional shot.


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## btadlock1 (Nov 11, 2011)

kbarron said:


> How can you bill components of the vaccine when CPT clearly states "it is inappropirate to code each component of a combination vaccine separatey". In NH Medicaid has us bill 90460 for first admin and 90460 w/modifier U1 for each aditional shot.



What you're referencing is talking about the actual vaccine code - not its administration. For example, if a patient gets an MMR triple-shot vaccine, it wouldn't be appropriate to bill the product as 90704 (mumps only), 90705 (measles only), 90706 (rubella only).  

The admins are a different story: for whatever reason, AMA has decided that pediatricians are special, and should be reimbursed for vaccine admins based on the number of components in combo drugs, and not by the number of injections/other types of admins given. It doesn't make a lot of sense to me (Why aren't family practice docs paid more for giving TDaP admins?)  - it's not like there's extra work involved in administering combo vaccines, just because they've got more than one product in them, and in my opinion, the admin codes should be based off of the actual _work done _- they've already been paid for the products. 

A shot's a shot, and patients receiving combo vaccines tend to get treated in exactly the same manner as those who receive individual vaccine products - you watch them to make sure they tolerate it, tell the parents what to watch out for, and send them on their way. The 'counseling' provided doesn't really change much, either (you may notice some swelling/redness at the injection site, or a slight fever, etc.). 

Many state Medicaid providers tend to agree with that sentiment, and have devised ways to work around paying extra for admins that weren't truly separate 'administrations' - some will flat-out deny the extra components as duplicates, but most have required that they're billed in a certain way (usually, it's more of a pain than other payers' requirements - Medicaid isn't famous for doing things efficiently), and they've adjusted their reimbursement methodologies, to cause the payments for individual and combo products' admins to be relatively close to one another. (For example, if they paid $30 for 90465 in 2010, they might pay $20 for 90460, and $5/unit for 90461x2, for an MMR admin in 2011).

Not to mention, the reporting structure for 90460/90461 is *completely* backwards from that of 90471-90474, or from their predecessors, 90465-90468, which *are* based off of the number of physical admins, irrespective of the products administered. The whole thing is really confusing, and seems unnecessary. Where I'm from, the saying goes, "If it ain't broke, don't fix it." I think that's applicable, here. 

If nothing else, they could at least be _consistent _- if combo vaccines warrant reporting extra admin codes, it should be that way for all vaccines (and even therapeutic drugs), regardless of age/product/route of administration. But nobody asked me, so here we are...


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## diane.smith409 (Nov 21, 2012)

We've been having a problem with the number of units billed. Medicaid has told us that there is a limit of 7 units for the second 90460 that has the U1 modifier. We've gotten no real answer as to how to bill for more that 8 units. An example- vaccines given at the visit have a total of 10 components. Is it appropriate to bill 90460 X 1, 90460/U1 X 7, and 90460/U1 X 3? Or are we supposed to bill only one line with the U1 modifier and so the max number of units would be 7 even though more were given. Does anyone have an answer on this?


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## GoLeun22 (Dec 11, 2012)

Wow..

 I am surprised that there are so monay having problems billing the administrations. I am in GA and have little to no problems whatsoever billing any insurance carrier. In the system that I use, we have a toggle to split by Dx or by DOS. I sometimes have upwards of 16 lines per DOS and bill all my admins un-grouped, but Dx specific. (We found we had more problems getting them to pay when grouped).

Ex:
99391
90723
90460       V06.8
90461x4    V06.8
90647
90460.76   V03.81
90670
90460.76   V03.82
90681
90460.76   V04.89
90715
90460.76   V06.1
90461.76   V06.1

Lisa


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## mbradfo2 (Dec 26, 2012)

We also have never had any issues with our method of billing - which is dx specific admin coding. Private or medicaid. 

Also, our billing software doesn't let coders do multiple units of 90460, so we couldn't do it the other way anyway.

Our medicaid (Florida) seems to work differently. They carte-blanche don't pay for ANY vaccine admins, but pay 10$ on each vaccine code for the administration (which they used to not pay on at all since the shots are all VFC). So, if you code 90716 and 90460, you get "not in contract" for 90460 and 10 dollars for 90716.  At least this is what we are seeing with our local Medipass and MediHmos.  I figure this is how they decided to keep their admin reimbursement low.


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