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 paid. Send a copy to your provider-relations person at the insurance company.
 
5. Send patients to a clinic. Although nobody likes to admit that this is a possibility the AAP firmly believes that every child should have one "medical home" another option is to send patients to a community clinic for all vaccinations. Again, however, you must check with the payer contract before you ask patients to go elsewhere for care.

Some payers might still be using the erroneous edits in CCI 6.1 that bundled 90471 and 90472 into certain E/M services (90296, 90371, 90375, 90376, 90379, 90385, 90389, 90393, 90396 and 99201-99455). The codes were inappropriately included in the CCI and were subsequently removed. If the insurer is still following these outdated edits, bring the change in CCI to its attention, and note that Medicare carriers are now reimbursing separately for these services.

Most pediatricians believe the culprit for the vaccine administration denials is likely the bundling software used by payers. McKesson HBOC makes the ClaimCheck software that more than 800 payers use for bundling edits. It appears that when a pediatrician codes a well visit and vaccine administration, ClaimCheck bundles the administration into the well visit.
 
McKesson HBOC says it uses CPT terminology and rules, and loads all modifiers and HCPCS codes into the packages. The company says ClaimCheck is not a medical payment policy and that only the insurance company can create the payment policy by how it uses the software. But ClaimCheck is known for the denial of an E/M service when performed on the same date as a procedure.
 
McKesson created this policy because it says CPT is unclear. McKesson also claims the software it sells allows the payers to turn bundling edits on or off, Schulte says. Whoever is ultimately responsible, the providers have to deal with the individual payers.

Cigna Faces Class-Action Suit

A class-action suit, with a pediatrician and an ENT as the chief plaintiffs, has been filed against Cigna over the use of ClaimCheck. Suzanne LeBel Corrigan, MD, a pediatrician, along with ENT Timothy N. Kaiser, MD, claimed breach of contract alleging that Cigna did not comply with PPO contracts specifically, that Cigna used ClaimCheck to bundle and downcode and failed to disclose the edits used to bundle or downcode prior to the time the services were rendered. After a March 29 class certification hearing, the nationwide class was appointed: All pediatricians who contract with a Cigna PPO may be parties. The plaintiffs seek compensation from Cigna for services rendered and injunctive relief requiring Cigna to disclose ClaimCheck edits.
 
Cigna denies the allegations and says its use of ClaimCheck is consistent with the contracts the software is used just to verify the accuracy of provider claims.
 
Any physician who was a preferred provider with Cigna from May 26, 1990, to April 20, 2001, is included in a certified class, as is any physician who submitted claims for covered services pursuant to such an agreement and any physician whose claims were audited by Cigna's ClaimCheck computer software.
 
Note: For more information, go to www.cigna-classcounsel.com or contact the class counsel at cignaclassattys@aol.com or call toll-free 888-837-8324.