Pediatric Coding Alert

Immunization administration codes 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]) are no longer bundled with evaluation and management (E/M) services. This Correct Coding Initiative (CCI) bundle, introduced in March 2000 (version 6.1), applied to Medicare only and was quickly rectified the next quarter.

But the status of the unit edit also mandated by CCI and which specifies that 90472 can be billed only once per day is still undetermined, according to Linda Walsh, MAB, senior health policy analyst at the American Academy of Pediatrics (AAP). This qualification makes no sense for a code that includes the phrase each additional vaccine in its descriptor.

The AAP is working through HCFA to change the unit edit. The problem was not intentional, Walsh says. We think it happened when [HCFA] updated the definition of 90472 from two or more to each additional.

Note: When the vaccine administration codes were first included in CPT 1999, the descriptor for 90472 specified two or more additional vaccines. Therefore, reimbursement was theoretically the same whether the pediatrician gave two or five vaccines. The descriptor was changed in CPT 2001 to read each additional vaccine, but HCFA did not include this change in the CCI.

For now the issue is academic, because there are no relative value units (RVUs) for either CPT 90471 or 90472. Nonetheless, many private payers do follow CCI edits.

Furthermore, there is some controversy about the necessity of assigning RVUs for these two codes. To remain competitive and perform well on reports used by employers to choose insurers (known as report cards), plans must show that their coverage includes vaccinations. In some areas, pediatricians are getting paid well despite the lack of RVUs. We think that some payers make an exception to the lack of an RVU when it comes to immunizing children, Walsh notes. In New York, for instance, Medicaid pays an administration fee of $17.85 for each vaccine.

Note: CPT 2002 will separate administration by oral and intranasal routes from administration by percutaneous, intradermal, subcutaneous, intramuscular and jet injections, Walsh advises. There will be new codes for oral and intranasal administration of vaccines. This will not affect pediatricians at this time, however, because the oral poliovirus vaccine is no longer given and the FDA has not approved the intranasal flu vaccine for children.