Pediatric Coding Alert

Pediatricians across the country have noticed with increasing alarm that payers are bundling vaccine administration (90471 and 90472) into preventive medicine codes (99381-99385 and 99391-99395). Because pediatricians administer vaccines at many of these well visits, the bundling represents an unacceptable revenue loss for many.
 
The CPT introduction to the preventive medicine section specifies that the immunization codes should be reported separately from well visits (and specifically references 90471 and 90472), notes Charles Schulte, MD, FAAP, chairman of the AAP coding and reimbursement committee.
 
"Unless they're Medicare or Medicaid, payers can do what they want," Schulte says. "When HIPAA takes effect a year from now, private payers will have to recognize the CPT Codes . But even HIPAA doesn't say they'll have to pay for them."
 
It's just not logical to bundle vaccine administration into the well visit, notes practice administrator Carol Gilchrist, RN, CMM, of Gilchrist and Galvin in Chelmsford, Mass. "Medicaid pays an administration fee," she says. "Why not the private payers?" Also, not every well visit includes vaccine administration a baby may get 16 vaccines during the first year of life, while a 3-year-old or an 8-year-old may get none. It makes more sense to pay separately for administration, she stresses.
 
Fighting Back
There are at least five avenues for "fighting back" against payers that do not reimburse separately for vaccine administrations.
 
1. Contracting. Make sure your contracts with HMOs and PPOs specify that the company will pay for vaccine administration by code, says A.D. Jacobson, MD, FAAP, chairman of the AAP section on administration and practice management. "For pediatricians, this is a very important item. Getting it in your contract is the best solution."
 
2. Bill the parents. Another option is to have a mechanism in place whereby the parents will be billed for vaccine administration if the insurer doesn't pay. Bear in mind, however, that you cannot balance-bill the patient if the managed-care contract considers vaccine administration a covered service. Also, there is some concern that the extra fee (probably around $15 for a single administration, somewhat less for each subsequent administration) would deter parents from bringing children in for immunizations. "This is where the reimbursement problems affect quality of care," Jacobson says. "It's a real concern in pediatrics."
 
3. Contact your state AAP chapter. In Arizona, for example, the state chapter is gathering data on the "hassle factor" (you can get a form from the AAP). That puts the state's pediatricians in a better position to lobby. "It's hard to do anything as an individual," Jacobson stresses.
 
4. Write the insurance commissioner. Your state insurance commissioner is the watchdog over insurance companies. Send information about the two code sets, including the verbiage from CPT indicating that they should both be [...]