Pediatric Coding Alert

When faced with rejections for multiple shot administrations, try vaccine diagnoses, a one-line entry or a last-resort modifier.

"We have recently begun billing for +90472 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; each additional vaccine [single or combination vaccine/toxoid [list separately in addition to code for primary procedure])," writes Peg McCarthy, accounts receivable supervisor for Pediatric Health Association in Naperville, Ill. Payers are rejecting the code as duplicates.

If the same problem plagues you, apply one of four techniques illustrated in this case study:

At an 11-year-old established patient's preventive medicine service (99393, Periodic comprehensive preventive medicine reevaluation and management of an individual ... late childhood [age 5 through 11 years]; V20.2, Routine infant or child health check), a nurse administers three vaccines, which include:

• Dtap -- 90715, Tetanus, diphtheria toxoids and acellular pertussis vaccine, when administered to individuals 7 years or older, for intramuscular use; V06.1, Need for prophylactic vaccination; diphtheria-tetanus-pertussis, combined (dtp) (Dtap)

• MCV4 -- 90734, Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use; V03.89, Need for prophylactic vaccination and inoculation against bacterial diseases; other specified vaccination

• a catch-up MMR -- 90707, Measles, mumps, and rubella virus vaccine (MMR), live, for subcutaneous use; V06.4, Need for prophylactic vaccination; measles-mumps-rubella (mmr).

To show insurers that each 90472 is for a different product, use the same ICD-9 code that you use with the vaccine product with the administration code, said Joel Bradley, MD, FAAP, in "Stop Losing CASH NOW: Beat the Challenges of Vaccines Coding Today" at The Coding Institute's Pediatric Coding and Reimbursement Conference 2007 in Naples, Fla. Using this technique, you would enter the above case study on a CMS form as follows:

2. Switch to V20.2 for Limitations

You may face restrictions, however, on how many diagnoses you can list. "Our system allows only two diagnoses," says Barbara Morgan in North Carolina. When she has several immunizations to report using 90472, she can't list all applicable ICD-9 codes.

Solution: Although itemizing each diagnosis is optimal coding, lumping multiple 90472s under V20.2 is also OK, Bradley says. "You can use V20.2 for all vaccines given during a preventive medicine encounter."

Using this strategy would change the above claim to read:

Future: When your system restricts the number of diagnoses you can report, you're going to have to find a long-term remedy. If your billing system won't take more than one diagnosis, you need another vendor, says Nancy Reading RN, BS, CPC, CPC-I, vice president of educational services for the American Academy of Professional Coders in Salt Lake City.

If line limitations cause your billing software to split a claim involving multiple 90472s, the insurer may receive a claim for 90472 that omits the required initial vaccine administration code, such as 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]). To avoid this, bill multiple units of service on one line for this 90472 procedure code related to the number of vaccine injections provided, Blue Cross BlueShield of Texas says.

Using V20.2 for all vaccine diagnoses would change lines five through seven in the above claim to read:

Beware: Although CPT places no maximum units on 90472, some insurers impose a frequency limit. For physician-purchased vaccines, Washington state's Health and Recovery Services Administration pays only two vaccine administrations. Therefore, HRSA limits 90472 to one unit.

When reporting multiple 90472s, rule out using modifier 76 (Repeat procedure or service by same physician). The modifier represents a procedure that the physician "repeated subsequent to the original procedure," according to CPT 2008 Appendix A -- Modifiers.

For insurers that deny multiple 90472s, a better modifier is 59 (Distinct procedural service), says Richard Tuck, MD, FAAP, a practicing pediatrician with PrimeCare Partners in Zanesville, Ohio. "In addition to the product being different, the injection site -- for instance, intradermal or intramuscular -- could be different as well."

You could use modifier 59 on subsequent 90472s. If you assign specific vaccine diagnoses, your claim could contain these items: