Pediatric Coding Alert

Immunizations, an essential and frequent aspect of pediatric care, are creating a coding crisis. The costs, hidden and direct, of giving shots are going up for pediatric practices, while reimbursements are going down. Many pediatric offices and clinics are finding that they are not even breaking even much less making money. Here are some tips for coding -- and for getting reimbursed promptly and fairly -- for the administration of immunizations and the vaccine itself:

Code for an office visit plus immunization. This is the most important tip. If youre giving an immunization, you need two codes. You should be coding for both the office visit and for the immunization, says Arnold Friedman, MD, chief of ambulatory pediatrics at Mt. Sinai Medical Center in Cleveland. Even if the managed care company wont pay you for both, its important to code accurately so you can document what you have done and eventually persuade them to reimburse you correctly and fairly. Use the lowest level of service for the office visit, and the appropriate immunization code.

For example, a new patient being seen by the pediatrician getting a DTaP immunization would be coded 99201 and 90700.

However, its more likely that you will be immunizing an established patient. For such a DTaP immunization, you would use CPT 99211 for the office visit and 90700 for the shot. The physicians presence, in this scenario, is not
required.

If your managed care company objects to your listing both codes it may help you persuade them to pay-up if you refer them to the AMA 98 CPT book. The introduction to the immunization codes states: Immunizations are usually given in conjunction with a medical service. When an immunization is the only service performed, a minimal service may be listed in addition to the injection.

Tip: You can try adding a 25 modifier to the office visit code. Ive seen insurance companies deny claims arbitrarily if there are two codes without a 25 modifier, says Thomas Kent, CMM, office manager for Esther Y. Johnson, MD, FAAP, Dunkirk, MD. It is not technically necessary, but adding a 25 modifier will often get this correct coding practice past the sloppy payor computer edits.

2. Read your capitated contracts carefully. Correct coding is especially important if youre working under capitation, says Friedman, who is also a coding trainer for the AAP. Dont assume that all capitated plans pay for the same thing -- they dont. Carefully read your contract before you sign it, and if it doesnt specifically include payment for the vaccine, make sure that they will cover it -- and include it in the contract. Otherwise, you are going to end up losing money -- a lot of money. There is no way that a $12 monthly payment will carry you through a newborns first year, and if you have a lot of newborns, you have significant up-front losses.

3. Wholesale vaccine reimbursement. Getting paid for the vaccines themselves, the most expensive part of immunizations, is tricky. For example, some insurance companies will tell you that they will reimburse you wholesale prices for the vaccine -- giving you a set amount -- which is probably less than you actually paid for it.

(Tip: Managed care companies can be excellent sources of information on where to get inexpensive vaccines. You should ask them where they got their suggested reimbursement figure, says Kent. When they pay too little, I ask them for the name of their supplier, he says. Then I can get the vaccine directly from that company, usually at a similar price.)

4. Collect co-pays. Every time someone walks into your office, collect a co-pay if the patients plan calls for it. Even though this sounds like common sense, many practices let small co-pays slip through the cracks -- but they quickly add up. Also, the receipt of a co-pay by your practice is tied in with the office visit for many HMOs. If you've collected the co-pay, it can make it easier to fight for office visit reimbursement, says Kent. Remember that HMOs cover immunizations because employers and patients demand it.

(Tip: Try to collect co-pays before the patient goes in to see the pediatrician. It gets the finances out of the way, and the parent doesnt have to stand in line with a screaming child after they've seen the doctor.)

5. If you have state-provided vaccines, keep them separate. These free vaccines are to be given to patients who have no insurance, who are on Medicaid, or whose insurance doesnt cover immunizations. They must be kept separate from the other vaccines, because the state can audit you to make sure you are not selling them (even by accident) to ineligible patients. I recommend buying a second refrigerator or having a completely separate shelf, offers Kent.

Incidentally, there can be a benefit to providing these state vaccines. The state determines what you can charge for the administration fee, and in many cases this is much higher than what the private managed care companies are paying. Medicaid in New York pays a $17 fee for the admini-stration of the vaccine, says Robert Long, MD, FAAP, of Lyndon Pediatric Associates in Fayetteville. At first this was on top of the cost of the vaccine -- a very generous program for pediatricians. They dont do that any more, says Long ruefully.

Under the federal program called Vaccines for Children, which is operational in all states, pediatricians can get free vaccines for all children who are Medicaid-eligible, uninsured, American Indians or Alaskan Natives, and underinsured (whose insurance companies do not cover immunizations).

(Tip: Those children who are underinsured must go to a public health clinic to take advantage of the program, according to Joan Mahanes, Medicaid immunizations liaison officer with the Health Care Financing Administration in Baltimore.)

Note: PCA subscriber benefit -- call 800/508-2582 to receive a fax containing a list of the free vaccines available by the state programs and contact names and numbers by state.

6. Keep track of your costs. If youre losing money on immunizations, youre subsidizing the managed care companies, says Mark Rafuls, practice manager for Tender Care Pediatrics in Miami. You have to know how much it costs you to buy a vaccine, and how much you are paying in indirect costs (i.e. the needle and the nurses time). Indirect costs are usually at least $5 per shot, adds Rafuls. Go to your HMO if they are not paying you enough, he suggests, and complain. Yes, the trend for HMOs is to reduce reimbursements for immunizations. But they will respond to challenges to their policies, Rafuls has found. If HMOs are going to keep pediatrics in their plans, they have to readjust.

Rafuls believes the point with vaccines is not to lose money. Youre not going to profit on vaccines, he says matter-of-factly. But you should at least break even.