Pediatric Coding Alert

Some pediatricians are being so poorly reimbursed for RotaShield, the rotavirus (RV) vaccine (90680), that they are wondering whether they should offer it. And some, like Charles A. Scott, MD, FAAP, a regional CPT coding resource physician for the AAP, are not even ordering it. And, says Scott, that may be the best route of all for many.

Managed care companies in our area have decided they would pay just barely over our cost, says Scott, who practices at Medford Pediatric and Adolescent Medicine in Medford, NJ. Were not giving it for that kind of compensation. So Scotts practice is simply not stocking the rotavirus vaccine at all.

The American Academy of Pediatrics (AAP), in a statement issued last fall (see PCA, Dec. 1998, page 91), gave pediatricians support for decisions like Scotts. Based on safety and efficacy data, RV vaccine is recommended for use in infants at 2, 4, and 6 months of age for prevention of RV infection, the AAP said. Then, however, the statement added: Routine implementation of this recommendation will require reconciliation of related economic issues.

This was the first winter that the rotavirus vaccine was available. Was there less rotavirus than usual? No, according to the Scott. We had a tremendous outbreak of rotavirus in the past year, he says. But the good news is that the children who had to be hospitalized for rehydration were all older children mostly around two or three years old not the high-risk group of infants. And they were not even admitted, says Scott of these children who did need intravenous fluids. They stayed in the ER for 12 hours on an IV, he explains.

Another solution, for pediatricians who really believe in RotaShield, is to ask the parents to pay for the vaccine, says Scott. Tell the parents, We have a vaccine thats available, but your insurance company isnt being honorable about paying for it, he says. Tell parents to hold on to their receipt in case the insurance company decides in the future to allow payment for the vaccine. At that time, they can resubmit the claim to the carrier for reimbursement.

Non-covered vs. Non-allowed Service

What if the managed care company objects to this kind of activism on the part of the pediatrician? If managed care says this kind of talk is against the contract, I dont want to hear that, says Scott. Its also against the contract for them to pay us six months late or not to pay us enough.

You are not required to collect from the patient if the code is denied. Billing for the rotavirus vaccine and writing it off if its denied is probably how many practices would handle this. However, it is very important to examine the reason for the denial. If the service was denied as a non-covered service, this means that the contract between the patient and the insurance company specifies that this service is not covered. In this case the practice should bill the patient, and not write off the charge.

If the service was denied as a non-allowed service, however, this means that the contract between the pediatrician and the insurance company specifies that this service does not need to be paid. The practice cannot bill the patient for a non-allowed service. Your options in this case are to appeal the denial or write off the charge. Also, you should consider renegotiating your contract to stop denials of future claims.

$15 Per Vaccine

Scott believes that pediatricians should be paid a minimum of $15 for every vaccine given. This means that the pediatrician should get $15 above what he or she pays for the product itself. Here in New Jersey the Vaccines for Children (VFC) program pays $11.50 per vaccine, says Scott. Some states pay more, some less. But if the child is not covered by VFC, and instead a private managed care company is paying, you may not cover your costs, says Scott.

The managed care companies can go to the legislatures and say, Were paying the pediatricians more than they are spending on the vaccine, says Scott. But how will I pay my nurses, my rent, my malpractice insurance?

Administration Codes

The new vaccine administration codes (90471 for one, 90472 for two or more) arent really solving the problem for Scott. But some managed care companies are paying well for these codes. We have a few that pay $20 for 90471, he adds. But some pay only $3.

Scott doesnt use 90472 at all, because it designates two or more and gives the pediatrician no way of getting reimbursed for giving, say, four instead of two vaccines a common occurrence in pediatrics. So we use 90471 for each vaccine, says Scott. If we give four, we link 90471 with each of the four. If you try doing this with 90472, you will probably be told that you cant use 90472 more than once, says Scott. And even though we actually should use 90472 instead of 90471, Scott explains, were doing trial and error with the insurance companies to see what codes they will allow. What happens when he uses 90471 four times? Sometimes he gets paid four times. In other words, an insurance company which reimburses 90471 at $20 may well pay you $80 in vaccine administration charges for that one visit (for the administration of four shots). However, the insurance company may well deny that claim as well.

Editors Note: Next year, the big administration fee problem will be resolved by the designation of the second code as being for each subsequent vaccine, rather for two or more. For this year, however, there are still serious problems with managed care companies interpreting the codes differently. A strict interpretation would say that you use 90471 for one vaccine, and 90472 for two or more. That means you lose money if you give four or five, as many pediatricians do in the early months. You may want to call each provider representative at the plans you contract with to find out how they are interpreting 90471 and 90472. You can negotiate a reasonable fee where necessary. But be cautious, anyone who gets $80 in immunization administration fees for one visit may be asked for it back some day, with little or nothing paid in the future.