Pediatric Coding Alert

Many pediatricians and office managers believe the recommendations for the use of Prevnar, recently released by the American Academy of Pediatrics (AAP), are not strong enough and should include recommendations for older children as well. The AAP issued specific recommendations for administering Prevnar to children under age two, but for patients over that age, the protocol is up to the physician. Pediatricians worry that the lack of information regarding older children may lead payers to believe they have an out when it comes to paying for Prevnar for older children. In addition, doctors are worried that managed care wont even pay for the doses for younger children as many as four doses, at almost $60 a shot.

Note: The AAP is sending letters to every managed care company urging them to pay for this important, potentially life-saving vaccine.

In the meantime, some pediatricians are trying to find other ways of getting paid for the vaccine. Here are some of the options.

1. Give parents a prescription. Richard H. Tuck, MD, FAAP, who practices with PrimeCare Pediatrics in Zanesville, Oh., has given parents a prescription for the vaccine. They go and buy it, and bring it back, and we give it, says Tuck. This bypasses the entire insurance system unless, of course, the pharmacy benefit covers it, which makes everyone happy.

2. A waiver. Some pediatricians are toying with the idea of having parents sign waivers, giving the physician the right to bill the parent if the managed care company wont pay for Prevnar. This is not necessarily a good idea, says Victoria Jackson, administrator/CEO of Southern Orange County Pediatric Associates in Lake Forest, Calif., and chair of the MGMA pediatric task force committee. The vaccine is not a non-covered service, so getting a waiver would be sticky, says Jackson. They would just say the fee for it is included in your capitation.

3. A new-technology clause. The best solution is to negotiate for a new technology clause in your contract. This wouldnt solve problems with Prevnar, but it would solve payment problems for any new vaccines that are developed. If you just have a straight contract, the managed care company will probably fight paying for the Prevnar, says Jackson. You have to think ahead of time, and let something in the contract that allows for new technologies, like new vaccines, to be paid.

A New Code

As we reported last month, the American Medical Association (AMA) has issued the CPT Codes 2001 code and descriptor for Prevnar (as well as some other vaccines) early. The purpose of this is to enable managed care companies to load the information so they can start paying the code as of January 2001, instead of waiting until their systems are loaded with new codes in April. The new code and descriptor are: 90669 (pneumococcal conjugate vaccine, polyvalent, for children under five years, for intramuscular use).

Releasing new vaccine product codes early is an excellent idea, says Charles A. Scott, MD, FAAP, who practices with Medford Pediatric & Adolescent Medicine in Medford, N.J. Vaccine approvals dont just occur at one time of the year, and since there are many new combination items in research studies that are just waiting for federal Food and Drug Administration (FDA) approval, we never know when a new one will finally make its debut, says Scott. Given that limitation, and given the tardiness of insurers to input new codes into their computers on a timely basis, a semiannual update is helpful to the practitioner, he notes. That way, we may not experience difficulties for an entire year using newly approved immunizations and codes hopefully, the longest time would be six months before a vaccine gains insurer recognition. If it were to take longer, notes Scott, the fact that CPT has assigned a new code would at least give pediatricians ammunition to combat the delay.