Pediatric Coding Alert

To get reimbursed for vaccine administration, you will have to educate your insurers on why they should cover these services.
 
Numerous pediatric practices struggle with payers that bundle the vaccine administration codes (90471, Immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections]; one vaccine [single or combination vaccine/toxoid]; and +90472, each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) into the vaccine codes (90476-90749). For instance, when billing a 2-month-old well check with four vaccines, insurers pay for CPT 90471 and maybe one or two 90472s, writes Heather Zambrana, billing and collection manager at Farrell and South Riding Pediatrics in South Riding, Va. But they deny the one or two remaining 90472 codes as duplicates.
 
If frequent denials also plague your pediatric practice, consider five tips to help you get payers to cover vaccine administration codes (90471-90472).

1. Check Your Vaccine Guidelines

Before you assume that the extraneous denials for the additional 90472s are a mistake, make sure your state allows you to bill each 90472. Although 90472s descriptor says each additional vaccine, some state vaccine programs have unusual rules, says Gena Davis, medical reimbursement specialist at Growing Up Pediatrics in Cornelius, N.C. In North Carolina, we can only bill for one 90471 and one 90472.
 
She says that despite the restriction, she has had no problems with reimbursement for the administration codes.

2. Inform Payers Administration Requires MD Work

Barring no unusual state immunization policies, you should understand why some payers think the vaccines include the administration cost. Some insurers are reluctant to reimburse vaccine administration because the National Physician Fee Schedule indicates that 90471-90472 do not contain any physician work relative value units (RVUs), says Albert D. Jacobson, MD, CPA, medical director at Pediatric Associates in Phoenix.

Point out that the RVUs contradict physicians recommendations. Although CMS thinks that 90471-90472 require no physician work, the relative value update committee (RUC) and the American Academy of Pediatrics maintain that they do. CMS argued that the codes involve no physician work because nurses administer the vaccinations, Jacobson says.

Tell the insurer that administering vaccines does require your pediatricians time. In addition to counseling parents regarding the risk factors and benefits associated with vaccines, pediatricians must supervise the administration. Faced with increased antivaccination information, parents require more education on the benefits vaccines provide, Jacobson says.

3. Send CPT Notes Showing Nonbundled Services

Use CPT documentation to bolster your case that 90471-90472 entail physician work, says Victoria S. Jackson, administrator at Southern Orange County Pediatric Association in Lake Forest, Calif.

In fact, CPT states that the vaccine codes do not include administration in two subsection instructions, Jackson says. The immunization administration guidelines for vaccines/toxoids state: Codes 90471-90474 must be reported in addition to the vaccine and toxoid code[s] 90476-90749. In addition, the vaccines/toxoids notes state: Codes 90476-90748 identify the vaccine product only.

Copy and send both CPT guidelines to the payer, Jackson says. Include a letter explaining that CPT specifically does not bundle the administration with the vaccine codes.

4. Itemize Administration Costs
 
If insurers still balk at paying for 90471-90472, show them how much the service costs your practice, Jacobson says. Most insurers dont realize all the work and time that goes into administering the vaccines, he says. Itemizing your vaccine administration costs (90471-90472) will help insurers see how extensive the pediatricians services are. A sample list to complete and submit to the insurance company follows:
 
Administration costs, staff time spent:
      ordering vaccines
      administering injections
      filing claims and appeals
  Physician work:
      time spent discussing benefits and risks with the
     patient and/or family member
  Storage costs:
       refrigerating the vaccines
  Supply costs:
       needles
       syringes
      vaccine information handouts.

5. Use Referral Strategy

If a breakdown of the actual costs does not help, inform the insurer that without proper payment you will have to refer vaccinations to a public-health facility. Inform the payer that sending the patients out will cost the plan more, Jacobson says.

Hopefully, the payer will see the light and grant you the reimbursement that you deserve, Jacobson says. During his contract renegotiations with Cigna in Arizona, Jacobson successfully used cost itemization and referral comparisons to get higher reimbursement rates for 90471-90472.