Pediatric Coding Alert

Pediatricians need to keep an eye on payers to make sure they heed CPT when it comes to the use of 90471 and 90472these codes are in jeopardy of becoming bundled into the evaluation and management (E/M) services codes.

The new vaccine administration codes (90471, 90472) were almost rendered useless when the Health Care Financing Administration (HCFA) issued its Correct Coding Initiative (CCI) edits for April 1. The CCI Edits are issued to say what codes are bundled. Apparently, Medicare thought providers were overusing these codes with E/M services, and HCFA was going to bundle the vaccine administration codes into the E/M services codes. If the edit had gone through, Medicare would have set the standardno billing of E/M services with vaccine administration. It would have been only a matter of time before private payers, who are reluctant to pay these codes, followed suit.

But the bundling edit did not take place, thanks to the American Academy of Pediatrics (AAP). The AAP had fought hard for these codes; pediatricians, after all, give far more immunizations than any other specialty. But it wasnt easy to convince HCFA to keep the edit out.

The vaccine administration codes, if bundled into E/M codes, would be used only when the child came in for immunizations only. And then you would not be able to bill for 99211 as well.

This should serve as a wake-up call for pediatricians: You are going to have to watch payers carefully and make sure they heed CPT when it comes to the use of 90471 and 90472. If Medicare (which has not even assigned an RVU to these codes and therefore, theoretically at least, isnt even paying for them) is worried, then private payers are surely going to work on avoiding the payment. We will keep you updated on this issue.