Pediatric Coding Alert

When CMS issued the fee schedule for 2002, it did not publish any work value for the vaccine administration CPT 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections]; 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]). Because CMS views vaccine administration as performed by a nurse, not a physician, it assigned only the value associated with practice expense and professional liability. But pediatricians do perform work in vaccine administration.

The pediatrician must convince the parents that vaccines are safe and necessary. "There must be a discussion with the parents on multiple vaccines, side effects, and the reasons and need for vaccination," says Charles J. Schulte, III, MD, FAAP, CPT adviser for the American Academy of Pediatrics (AAP) and practicing pediatrician in Washington, D.C. "There's a big antivaccine lobby, and counseling now takes up a lot of time."

A physician can upcode an E/M service based on time if more than 50 percent of the encounter time is spent on counseling. But vaccines usually are given during a preventive medicine visit, so it is not possible to upcode. A work value for vaccine administration is necessary.

One solution, although not clinically optimal, is to send patients to a public health clinic for vaccination. Another is to lobby, which the AAP recommends. "Use the members-only channel to send a letter to legislators, to gather signatures in support of a work value for vaccine administration," says Linda Walsh, senior health policy analyst with the AAP division of healthcare finance and practice. "We're only working on the first two codes now."

The other two administration codes 90473 (Immunization administration by intranasal or oral route; one vaccine [single or combination vaccine/toxoid]) and +90474 ( each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) were added with CPT 2002. Codes 90473 and +90474 present an additional hurdle because CMS maintains that oral and intranasal vaccinations are self-administered. This may be true for Medicare patients, but not in pediatrics. At this point, however, no oral or intranasal vaccine products are available, so the AAP is concentrating on getting the physician work value in the first two codes.

Commercial payers tend to adopt the Medicare fee schedule when setting rates for codes, and these rates will be too low because they will not represent any physician work.