Pediatric Coding Alert

Expansion of the federal Vaccines for Children program to include private pediatric practices has been a godsend for uninsured and underinsured children who might not otherwise be able to get needed immunizations. However, correctly coding and accounting for these vaccines has been a challenge for many pediatric practices.

Pediatricians administering the vaccines need to collect an administration fee for giving the shots, but cant code the regular CPT code if they recieve the vaccine for free. And, even if they get the shots without cost, they must document the number and type of vaccines given.

Background

Coding for state-supplied vaccines depends largely on what is happening in your state. The federal Vaccines for Children (VFC) program is designed to make sure every child in the country is immunized, regardless of income or insurance coverage.

In most states, to be eligible for VFC vaccines, children must either be enrolled in Medicaid, uninsured, American Indian or Alaskan native, or underinsured (with medical insurance that does not cover immunizations), and underinsured children must go to a public health clinic for the vaccines.

Some states, however, have discovered that this creates fragmentation in health care, and they have allowed all practices to receive free vaccines. In these states, underinsured children do not have to go to clinics for immunizations, but can get them directly from their pediatricians.

There are also universal states which allow all chldren to receive free vaccines. These universal states are Alaska, Colorado, Connecticut, Idaho, Maine, Massachusetts, Nevada, New Hampshire, New Mexico, North Carolina, North Dakota, Rhode Island, South Dakota, Vermont, and Washington. In these states, pediatricians do not purchase vaccines from pharmaceutical companies; the states do, and then give them to pediatricians for free.

You need to contact your state VFC representative for particulars on how the program works in your state.

The Administration Fee

When billing for these state-supplied vaccines, there are two key points to remember: one is that CPT clearly states that you should code for administration if an immunization is all you are doing (using CPT 99211 ); and the other is that, even if you are not getting reimbursed for vaccines because they were no cost to your practice, you must get those immunization codes in the record so it is documented that you have given the shots.

If were billing for the immunization itself, we bill the appropriate CPT code, says Barbara Hoag, billing supervisor for Pediatric Healthcare Associates, an 18-pediatrician practice in Trumbull, CT , a universal state. And, if its a state-supplied vaccine, we can charge a 99211, which covers the administration fee.

The free vaccines come with an administration fee that is reimbursed by the insurance company or by Medicaid. In universal states, every free vaccine (which means every vaccine given in certain states), comes with an administration fee, for which there is no CPT code. Pediatricians are allowed to bill Medicaid an administration fee, providing that fee doesnt exceed federal limits. In most states, the administration fee is provided across the board at set rates.

The key problem for free vaccines is how to capture the administration fee. We called several coding experts in practices in different states to find out how they are tracking and filling out claims for state-supplied vaccines given as immunizations.

1. Basic three concepts. In North Carolina, a universal state, there are three basic concepts to keep in mind, says Stuart Tucker, MD, an internist at the 130-pediatrician Nalle Clinic in Charlotte, NC, and medical director of Maxicare, a health plan based in Charlotte, NC. AWhen a state-provided vaccine is used, the biller overrides the price in the computer and puts a zero-dollar charge, says Tucker. If the patient comes in just to get a private vaccine, with no well-visit, they get the vaccine code and the fee-for-service price or the vaccine. If the patient comes in for an office visit and an immunization, they get the office visit code and a vaccine code (again, with the price for the vaccine overridden if a state-supplied vaccine is used).

2. State codes. There are also state codes that must be used in order to get reimbursed, says Tucker. In North Carolina, the state will pay for the professional component, or the administration fee, he says. We have to use HCPCS Level III codes, he says, noting that these codes differ depending on what state youre in. There are different codes depending on how many vaccines you are administering at once. For example, in North Carolina, W8012 is for one shot, and W8013 is for two or more.

3. Administration fee covered in office-visit charge. CPT states that when an immunization is the only service performed, a minimal service may be listed n addition to the injection, so a 99211 is the appropriate code. Furthermore, insurance companies are paying it, says Pediatric Healthcares Hoag. If the immunization is given as part of a well-visit, the well-visit codes (99381 - 99387 and 99391 - 99397) cover the administration fee.

4. Modifier 26. Some insurance carriers tell us to use the modifier -26, Hoag continues. Modifier 26 is for the professional component. Certain procedures are a combination of a physician component and a technical component, the CPT book states. When the physician component is reported separately, the service may be identified by adding the modifier -26 to the usual procedure number. In this case, Hoag would use the modifier -26 on the immunization code, and then charge an administration fee. Theres no code for the fee, says Hoag, but she charges $15.75 which is equivalent to the 99211 charge.

Tip: If an insurance carrier requires you to use the modifier -26, then you have to do so. But this is technically not the correct way to code for immunizations, so its a good idea to get it in writing if your carrier does require such coding.

5. Zero charge. This is a fairly common way of dealing with the CPT code for the immunization, which needs to get reported so that the fact that the immunization was given is on record, but which isnt going to be reimbursed because the practice got the vaccine for free. We use the CPT code for the immunization as if we were charging, but then put a zero charge against it, says Barbara Grogg, office manager for Children and Adolescent Medical Services of Tulsa, OK, which is not a universal state. If its a state vaccine, we use the W-code to get reimbursed for the administration (W4830 in Oklahoma). Some carriers require this method instead of the modifier -26, perhaps because their computers wont take the modifiers.

6. Negotiating for the administration fee. In Pennsylvania, which is not a universal state, Blue Cross/Blue Shield will pay a small administration fee for all injections ($1.20). But Laurie Kline, CMM, the office manager for Lehigh Valley Pediatric Associates of Allentown, recommends that you negotiate with the various HMOs for an administration fee.

Fight for the administration fee, she says. You have to get it into the contract.

7. Why the administration fee counts. Practices need to charge an administration fee, says Carol Gilchrist, CMM, practice manager for Michael A. Gilchrist, MD and Sheila M. Galvin, MD of Chelmsford, MA, a universal state. We provide education when we give immunizations, says Gilchrist. We show parents a video, we give out packets at the one-month visit, and we talk to the parents about the immunizations.

8. Medicaid wont always pay administration fee. In Massachusetts, Medicaid will not pay an administration fee for the vaccines, says Gilchrist. But, they will always pay for the office visiteither the well visit or a nurse visit (99211). A private HMO, however, will pay for an office visit plus an administration. ABut, I cant get real upset that Medicaid wont pay for administration, since they are paying for the visit, says Gilchrist.