Pediatric Coding Alert

When the Food and Drug Administration licensed RotaShield earlier this year (August 31), pediatricians across the country were faced with a dilemma: whether or not to immunize their patients with this new vaccine.

Rotavirus infection results in about 50,000 pediatric hospitalizations a year, according to statistics kept by the American Academy of Pediatrics (AAP). In fact, one in 78 children is hospitalized with rotavirus-related diarrhea by age five.

The 1999 CPT includes a code for the vaccine (90680), but there is still some uncertainty about how much insurance companies will pay for it, or if they will pay at all. Even the AAP, which issued an alert to its members endorsing the rotavirus vaccine (RV), recognizes that there is a problem.

Based on safety and efficacy data, RV vaccine is recommended for use in infants at 2, 4, and 6 months of age for prevention or RV disease, the AAP states in the alert, which was issued on October 22. However, the statement continues to say, Routine implementation of this recommendation will require reconciliation of related economic issues.

Aetna/U.S. Healthcare has said it will pay $41.50 for 90680, says Charles A. Scott, MD, FAAP, an regional CPT coding resource physician for the Academy who practices in Medford, NJ. Thats only two dollars more than our cost, he says. If Cigna pays $15 to administer it and another company pays $2, I still have to give it to both groups of patients, he says. I cant justify giving it to Cigna members and not to other patients. The AAP, in referring to economic issues, is letting pediatricians know that routine use of the vaccine may not be feasible. Theyre giving us an out, says Scott.

With rotavirus season fast approaching, Scott, like other pediatricians, wasnt sure how to respond to the sales representative from Wyeth-Lederle, the maker of RotaShield. The AAP had been silent on the rotavirus vaccine until the member alert went out, so there wasnt any clear set of guidelines. We did have a big order in, but we canceled it because of the insurance problems, says Scott, who notes that none of his patients parents have brought the issue up.

Insurance companies are expected to consider the money that will be saved though prevented hospitalizations, and may decide to reimburse at an adequate rate for the vaccine for
that reason.