Pediatric Coding Alert

In CPT 1999, there are 24 new codes and 30 revised codes for vaccines. In addition, there are two new codes for their administration. These changes reflect the development of several new vaccines, as well as new product-specific codes given to existing vaccines. There are also multiple codes for some drugs when administration schedules differ based on age or dose. And, while we hear that many insurance companies are slow to get the new and revised codes on their systems, most will finally be updated by April (the date that Medicare has set for implementation of the new codes).

This means pediatric superbills need to be changed, according to the American Academy of Pediatrics RBRVS Project Advisory Committee (RBRVS PAC). As the RBRVS PAC states in its winter coding and reimbursement update: If pediatricians had not planned to revise their encounter forms this year, they should think again!

Changing the Superbill

How are practices coping with the changes? Tina Cressman, CPC, reimbursement analyst for the 45-pediatrician Cooper Health System in Camden, NJ, is doing a two-phase change of her superbill this year. We put in the other new codes in January, but for the vaccines, were waiting until April 1, says Cressman. Thats because we found a lot of insurance companies wont be accepting the new vaccine codes until then. Cressman will hold off on putting the new vaccine administration codes (90471 and 90472) on the superbill until April, as well.

And she stresses that it is very important for the precise vaccine code to be on the superbill. The pediatrician should be the one indicating the service, says the coder. This cant be left up to translating from notes or cheat sheetsthat just makes an extra step where an error can be made.

Lynn Bloom, insurance administrator for Maple Avenue Pediatrics, a four-pediatrician practice in Fair Lawn, NJ, agrees that there are problems with the new vaccine codes. I am seeing recognition for the new rotavirus vaccine code (90680), but not for the administration codes, she reports. "My EOBs all say invalid CPT Codes . Bloom has decided not to file the new administration codes until she has some indication that the managed care companies she works with will recognize them.

This is one optionwe can understand why someone wouldn't want to re-file all those claimsbut that doesnt mean you cant be ready with the updated encounter form.

But not all practices want to add the new vaccine product codesat least not on the pediatricians encounter form. Barbara Brenton, office manager for North Park Pediatrics, a four-pediatrician, one nurse-practitioner practice in Bellair, MD, wants to keep the superbill easy to read. We have elected to keep things very simple in terms of vaccines, Brenton explains. It would be very confusing to the staff.

While Brenton did change the superbill to allow for the new administration codes (90471 and 90472), she is not going to put the new vaccine product codes on the superbill. Instead, her coding staff will write in the appropriate code. First, the nurse gets the signature from the parent when the child is vaccinated, says Brenton. The parent writes in the vaccine product name, with the lot number. Then, the coding staff transcribes directly from this form onto a blank slot on the superbill for the appropriate CPT code. The coders have a list of the 1999 vaccine codes to refer to.

Karen E. Dufault, coding manager for Bridgewater Goddard Park Medical Associates in Brockton, MA, does have the new product codes on her superbill, although she sometimes does this by leaving the last digit missing. For example, she lists 9074_ for hepatitis B. The staff fills in the last digit that corresponds to the code for the amount of vaccine used. (See below.)

The Hepatitis B Problem

In fact, hepatitis B vaccinations are an excellent example of the reimbursement problems associated with the new vaccine product codes. Its not just a matter of getting the number right for recordkeeping purposes.

Until last year, the pediatric and adolescent dose for the hepatitis B vaccine used to be different: Adolescents would get twice the amount as young children. That is why there used to be two separate codes used by pediatricians, which were defined by age: 90744, for newborn to age 11, and 90745, for age 11 to 19. The higher dose was indicated by 90745, and reimbursed at a higher rate; the lower dose was for 90744. Last year, however, the Food and Drug Administration approved giving the higher dose to all ages. And thats the standard of care now, says Charles A. Scott, MD, FAAP, of Medford Pediatric and Adolescent Medicine in Medford, NJ. You have to give the little kids and the big kids the bigger dose.

But, guess what? There is no longer an age definition in the CPT codes for the hepatitis B vaccine. The code that was used for the smaller dose, 90744, is now defined as being for the pediatric or pediatric/adolescent dosage; the code for the higher dose, 90745, is defined as being for the adolescent/high-risk infant dosage. This means that every time you use 90744, you are losing money. That code is for the lower dose, but you are only giving the higher dose. However, you are giving the higher dose to pediatric and adolescent patients because it is the most appropriate care.

Now were giving the big-guy dose to everyone, but only getting paid for the little-guy dose, says Scott. The insurance companies have not increased the relative value units associated with 90744, even though it now reflects use of a larger dose of medicine.

Note: The CDC has noted this change in its recommended immunization schedule. Anyone using the Recombivax HB vaccine, manufactured by Merck and Co., now will be using the standardized five-microgram dose for children from birth through 19 years of age, regardless of the mothers hepatitis status. The other available hepatitis B vaccine, Engerix B, manufactured by SmithKline Beecham, also has a standard dose for all children from birth through 19 years of age:10 micrograms.

Scott does have a solution. Bill 90745 for every hepatitis B vaccine product. Thats what our practice does, he says. I am viewing everybody as high-risk, and coding all the hepatitis B injections 90745. The reimbursement is a little higher than 90744, and its a fair way of getting around the problem. I think that 90744 has become obsolete, says Scott.

Administration Codes and Multiple Injections

Another reimbursement problem associated with the new codes is how to get paid for multiple injections. In the words of Ken Katz, MD, FAAP, of Littleton, CO: How do you code if you're giving more than two single or combination vaccines? he writes. I understand that 90471 is for one, and 90472 is for two. What about three? We give IPV, acellular DPT, and HIB as three separate injections.

Well, actually, 90472 is for two or more single or combination vaccines. This doesn't seem fair, but Brenton has found a way to deal with the problem. You need to charge the number of units you give, she says.

If a child is given three injections, for example, Brenton shows it on the claim by listing the vaccine code, and assigning the proper number of units to the multiple-administration code 90472. I put in $15 per shot to administer each, which is the fee weve chosen, says Brenton. She recommends that you put whatever fee for administration you have determined for your fee schedule. You know you wont get paid that amount, but you have to start somewhere, she adds. And its working. Blue Cross/Blue Shield is paying her $5.00 for one shot, $9.00 for two shots, and $12 for three shots.

Just about everybody is paying us by units now, says Brenton. As long as you indicate the number of shots you give in the unit column, you can get reimbursed for more than two, says Brenton.

Tip: Dont forget to change your software to allow you to put in units for injections.

Brenton stumbled upon this solution in the way many coding mysteries are solved. A coding-minded office manager, she realized that she wasnt getting reimbursed properly when the practice gave more than one allergy shot. When we gave a shot in the left and right arms, it wasn't enough to just bill 95117 (two or more allergy injections), says Brenton. We were still only getting paid for one. So Brenton started putting down two units next to the 95117, to show that two shots were given (even though the code means that two shots are given). It worked: The insurance companies paid properly.

How much should you charge for administering vaccines? This is a tricky one, since HCFA didnt assign an RVU to either code. You need to be compensated for the time it requires to take a history, counsel parents, obtain informed consent, and actually administer the vaccine. You also need to consider your expenses for storage, and for supplies such as syringes and swabs. Bear in mind that you probably won't get what you put on your fee schedule, but you should have a realistic figure there anyway.

Diagnosis Coding for Administration Codes

D. Burke, the biller for Peachwood Medical Group of Clovis, CA, asks What diagnosis code should be used with immunization administration codes 90471 and 90472? Gillis L. Payne, MD of Montgomery, AL has the same question. The answer is V20.2 (routine infant or child health check)the same diagnosis code you use for the preventive services CPT code. I always use V20.2, and it has been going through beautifully, says Brenton. The only exception is one insurance company that hasnt loaded the administration codes yet.

When the vaccine is administered outside of the well-child physical, you should use V03.x, V04.x, V05.x, or V06.x diagnosis codes, which apply to specific vaccinations. We hear that some practices use V05.8 (other specified disease) or V06.8 (other combinations) in all situations, one for single vaccines and one for combinations, with good results.

What about Synagis?

Speaking of unrecognized vaccine codes, pediatricians are still waiting for a CPT code for Synagis, the new intramuscular respiratory syncytial virus (RSV) vaccine which replaced RespiGam, the immune globulin which was administered intravenously (and very slowly). For the time being, you need to use the unlisted vaccine code90749.

But the CPT code is the least of the reimbursement problems with this vaccine, as anyone who tried to use it this winter learned. The product costs about $900 for a single dose. Practices which purchased it, administered it, and then tried to collect found they were getting stuck with the tab. Even if you only have a couple of patients who need it, this can be an alarming prospect.

The solution, says Brenton, is to use the patient's pharmacy benefit, bypassing the regular insurance. I have one of the staff investigate the childs pharmacy benefit, and if it will cover such an expensive drug, then we can use that, she explains. In three of the five cases in which the practice has used Synagis, the pharmacy benefit did cover 100 percent of the cost. For the other two cases, Brenton went to the major medical portion of the insurance, and asked the company to pay for the vaccine. In both cases, it did. That way, we dont have to purchase the Synagis up front, and try to collect later, Brenton notes.

No, Brenton isnt making money on this. But she isnt losing money either, as several practices told us is the case with their use of Synagis. It is a PR thing, Brenton says. Were administering it as a courtesy. Parents of premature babies have a lot to worry about, and preventing RSV is high on the list. So anything a pediatrician can do to help is appreciated. Brenton admits that it can take quite a bit of staff time to coordinate the payment, whether its with the pharmacy portion or the major medical portion of the insurance. Nevertheless, she says, its well worth it.

Esther Y. Johnson, MD, FAAP, of Dunkirk, MD, doesn't believe that pediatricians should ever pay for Synagis, because denied payment on just one dose can wipe out a big chunk of one months profits. So she tells parents to request the medication directly from the insurance company. The insurance company purchases the vaccines and ships it directly to our office for administration, she says. You simply have to instruct the patient how to make the request.

By the way, MedImmune, the manufacturer of Synagis, has a support line for providers(877) 633-4411. You can get local Medicaid codes for the drug, when available, from this number, as well as other reimbursement tips. Steve Collins, reimbursement and managed care manager at the Gaithersburg, MD-based company (which also makes RespiGam), thinks the reason for the payment problems is that no HCPCS code has yet been assigned. Providers are using J3490, the miscellaneous drug code, instead, and this is giving managed care companies pause, because the drug is expensive. His solution is to indicate that you have used Synagis in box 19 of the HCFA 1500 form. If you write Synagis, 100 milligrams, most insurance companies will cover it, he says.

Note: For a list of the new vaccine codes, see the November 1998 issue of Pediatric Coding Alert. To order a back issue, call 800/508-2582.