Medicare Compliance & Reimbursement

Always investigate denials for 90460 — here’s why.

For most pediatric practices, immunization is probably the fourth most important procedure. Children need to be administered vaccines — be it during well-visits or for visits with vaccination specifically in mind. Read on to learn why not collecting for the service can cause a major dent in your practice’s bottom line.

Analyses of pediatric billing patterns indicate that code 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered) is one of the most frequently billed procedures among pediatricians. But some practices tell Eli that it isn’t worth their time to go after reimbursement for this code if they get a denial.

Unfortunately, this point of view can cost your practice a lot of money down the road. “Pediatricians should always investigate denials, but particularly for such high-volume procedures as the immunization administration,” says Chip Hart, director of PCC’s Pediatric Solutions Consulting Group.

Hart says that code 90460 represents more than 12 percent of the CPT^® codes performed by pediatricians based on volume, but only 6.7 percent of their total payments. “The reason is simple: it’s not a high-dollar procedure, typically between $15 to $20 in payment,” Hart says. “But so many of them are performed, often multiple times during a well-visit, that it’s still the fourth most prominent procedure in terms of overall payments.”

Totals Add up Over Time

Even if you only report 90460 five times per day, that still means it’s worth $100 or more every day to your medical practice. If you’re open Monday through Friday every week, then you’re forfeiting $26,000 a year if you don’t collect for your vaccination services using this code. But that’s not the only reason you should appeal if you don’t get paid for 90460.

“The insurance companies, with no help from the clearinghouses, are very slow to recognize changes in the immunization administration coding scheme, so every fight you have to get it right helps one of your pediatric peers as well,” Hart advises. “Immunizations are among the most important services pediatricians provide — fight for what they are worth!”

To ensure that you collect for 90460 up front, always remember the following three quick tips about how to report this code properly.

1. Nurses Can’t Report This Code

Always remember that 90460 is not billable by a nurse because an RN cannot perform the counseling — only a provider or a qualified non-physician provider can perform the counseling portion. If a nursing staff member administers the immunization, they can report a code from the 90471-90474 series instead.

2. Remember the Add-on Code for Multiple Vaccines

If you perform more than one immunization on the same date, don’t report multiple units of 90460. Instead, bill 90460 for the first vaccine, and +90461 (…each additional vaccine or toxoid component administered [List separately in addition to code for primary procedure]) for each additional component.

3. Counseling Isn’t Optional

When your pediatrician administers a vaccine to a patient who is 18 years of age or younger and provides counseling about the vaccine to either the patient and/or to the patient’s caregiver, remember that 90460 requires counseling and not just the administration of the vaccine.

If you don’t perform counseling, the code will default to the original 90471-90472 set, which almost always leads to lower payment, Hart says.

Resource: To read more about the most frequently billed CPT^® codes by pediatricians, visit Hart’s website at http://chipsblog.pcc.com/pediatric-cpt-data-2015/.