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.

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