Pediatric Coding Alert

The Health Care Financing Administration (HCFA) implemented a unit edit on code 90472 (immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections and/or intranasal or oral administration]; each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) last April that said the code could be used only once a day. But the descriptor of CPT 90472 says it is for each additional vaccine. Because pediatricians often administer more than one vaccine to a patient on the same day, the unit edit creates a difficult contradiction.

Fortunately, pediatricians were not affected because the unit edit applied only to Part A of Medicare. But in October 2000 the edit will apply to Part B of Medicare, meaning it may start to trickle down to the commercial payers.

In an attempt to rectify the problem before October, American Academy of Pediatrics (AAP) officials contacted HCFA, and on Sept. 14, they received a letter from Terrence L. Kay, director of the division of practitioner and ambulatory care at HCFA, indicating that the agency is aware of the problem and that the AAPs points are well-taken.

In CPT 1999, 90472 was introduced and defined as being for two or more vaccines. In other words, the pediatrician would give one vaccination and bill 90471 (immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections and/or intranasal or oral administration]; one vaccine [single or combination vaccine/toxoid]) for the administration, and then give, for example, three vaccinations right after that and be able to bill 90472 only once. In CPT 2000, this problem was rectified by a descriptor change that defined 90472 as being for each subsequent vaccine. You administer four vaccines, you can code for four administration fees.

That is, until the unit edit last April. I said, Is it possible that they never updated the descriptor when they did the unit edits? asks Linda Walsh, senior health policy analyst with the AAP. And HCFA appears to be taking this under advisement. Its pretty promising that they will change the edit to xxx, says Walsh. This would mean that you could bill 90472 for each subsequent vaccine, as CPT states.

You can bill 90472 for each subsequent vaccine regardless of the unit edit if you are not filing with Medicare. The problem, of course, is the trickle-down effect of Medicare. The commercial payers buy the software from Medicare, and then, if they dont update it, youre stuck, she says. This is one reason why its so important to get Medicare mistakes fixed even if you are a pediatrician.

Use Modifier -25 on E/M Services with Blood Draws

As of Oct. 1, if you want to bill for a blood draw in addition to an evaluation and management (E/M) services code, you must put a modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) on the E/M services code, according to Version 6.3 of the Correct Coding Initiative (CCI). The blood draw codes included in this edit are listed below. Notably missing from the list is 36415* (routine venipuncture or finger/heel/ear stick for collection of specimen[s]). Most of the bundled blood draws are pediatric.

36400 (venipuncture, under age 3 years; femoral, jugular or sagittal sinus)
36405* (venipuncture, under age 3 years; scalp vein)
36406 (venipuncture, under age 3 years; other vein)
36410* (venipuncture, child over age 3 years or adult, necessitating physicians skill [separate procedure], for diagnostic or therapeutic purposes. Not to be used for
routine venipuncture.)
36420 (venipuncture, cutdown; under age 1 year)
36425 (venipuncture, cutdown; age 1 or over)
36430 (transfusion, blood or blood components)
36440* (push transfusion, blood, 2 years or under)
36450 (exchange transfusion, blood; newborn)
36455 (exchange transfusion, blood; other than newborn)
36460 (transfusion, intrauterine, fetal)

The problem with the new edit is that putting the modifier -25 on the E/M services code when billing the above blood draw codes may result in denial by insurance companies, says Charles Schulte, MD, FAAP, chair of the American Academy of Pediatrics (AAP) coding and reimbursement committee.

CCI is saying that blood drawing is a component code with 62 different E/M services codes. The academy has already complained, he adds, noting that all the pediatric venipuncture codes showed up on the list, but the adult blood draw code did not.

This means that you cannot code for a consultation or critical care or any other E/M services code in addition to one of these codes unless you use modifier -25 on the E/M service which may not work at all. So its better for the physician not to code for the blood draw at all, says Schulte. That way, at least you will be paid for the E/M service.

CPT Changes for 2001: Vaccines and Critical Care

The two main CPT changes affecting pediatricians for 2001 are the new and revised vaccines codes (see AMA Releases New Vaccine Product Codes Early in the July 2000 Pediatric Coding Alert for a complete list) and new verbiage for the critical care codes (99291-99292).

The introduction to the critical care codes will return to the pre-2000 stricter language. Last year, the introductory language was loosened, making it easier for pediatricians to bill critical care codes even if the child was not extremely sick. When the Health Care Financing Administration (HCFA) realized that this change meant more physicians would be using the critical care codes, it lowered the relative value. Now, with the language returning to greater restrictions, HCFA has promised to increase the relative value again.

Now it will be harder to use the critical care codes, but you will be paid more for them, says Charles Schulte, MD, FAAP, chair of the American Academy of Pediatrics coding and reimbursement committee.