Pediatric Coding Alert

CPT Codes 2000 solved the vexing problem of 90472 (its no longer for administering two or more vaccines, but rather for each subsequent vaccine), making it much easier for pediatricians to be fairly reimbursed when they give four or five vaccines. But managed care companies are undercutting the whole purpose of 90471 (immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections and/or intranasal or oral administration]; one vaccine [single or combination vaccine/toxoid]) and 90472 (each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]).

These commercial payers are saying the codes are bundled into the preventive-medicine services codes (99381-99397). Some insurance companies are claiming that you can use only the administration codes when there is no preventive-medicine services visit on the same day. This is how you know they are bundling the codes, even though this is not an official Medicare bundle. Rather, it is a maverick bundle adopted by some health plans that dont like the idea of paying for administration. And pediatricians, who give far more immunizations than any other physician group, are hard hit by this policy.

You dont have to accept it, says Curtis J. Udell, CPAR, president and CEO of Emphysys, a Cummings, Ga.-based firm that provides compliance services for physicians, including many pediatricians. But you do have to contact the payer and ask what theyre doing to offset your costs. This means that you need to make sure the money being taken out of the picture by not recognizing the administration codes is being put back in by adding more to every preventive-medicine services code. They should be adding another five or six dollars for the well visits, says Udell.

Richard H. Tuck, MD, FAAP, of Primecare Pediatrics in Zanesville, Ohio, and founding chair of the American Academy of Pediatrics committee on coding and reimbursement, agrees. In fact, Tuck took one health plan to task over this issue. I talked to the medical director and the quality assurance committee of Nationwide [the health plan], he says. I explained that this was against the emphasis being put on immunizations by the NCQA. (The NCQA accredits managed care plans, and employers look for this accreditation before selecting a plan, so following NCQA guidelines is given high priority by quality plans.) I explained that pediatricians will send children to the health department for immunizations if managed care plans wont cover the costs. Tuck is now waiting to hear from the plan on the results of his complaints.

The point is that you do have to say something to the plan. Emphasize that the new administration codes are to be used in addition to the preventive-medicine services visit, says Tuck. Theyre not just to be used when a child comes in for shots only.

Lack of RVUs is a Challenge

What doesnt help is the fact that the Health Care Financing Administration (HCFA) has not published a relative value unit (RVU) for 90471 or 90472. That means that when you try to calculate the value of physician work related to these codes, you come up with 00. Managed care plans that rely on HCFAs published RVU list in the Federal Register will not see any value at all in these codeseven though the RUC assigned them. CPT does say to use these codes, however, and pediatricians who are experts in coding say that something will be done about the RVU problem.

Well have something by early in the year, says Charles M. Vanchiere, MD, FAAP, chair of the AAPs committee on coding and reimbursement and CEO of Childrens Clinic of SW Louisiana in Lake Charles, of the RVU for the administration codes. In the meantime, pediatricians should use these codes, should bill them and should insist on payment for them, he says.

Charles Schulte, MD, FAAP, the AAPs representative to the American Medical Association's CPT coding committee, is so angered by the health plan bundling of immunization administration codes with preventive-medicine services codes that he is requesting people to contact him with examples of this happening. Let me know at schulte@aap.org, he says. If anybody is bundling that way, were going to have to take a very severe stance.

The bottom line, says Tuck, is that pediatricians need to be better business people. You need to press for the policies that are stated in CPT.