Pediatric Coding Alert

by Joel Bradley, MD, FAAP

This months columnist, Joel Bradley, MD, FAAP, is chief of staff-elect at Gateway Medical Center in Clarksville, Tenn., and a member of the American Academy of Pediatrics(AAP) Coding and Reimbursement Committee. He is also the editor of Coding for Pediatrics, published by the AAP and one of eight pediatricians in private practice with Premier Medical Group in Clarksville, Tenn.

Because the vaccine administration codes (90471-90472) are relatively new (many insurance companies dont start until April 1 with new CPT Codes for the current year), you should send a letter to your major payers stating how you intend to bill for the vaccines. Send a copy to the medical director; after all, that is the person who is in charge of clinical quality measures for a health plan, and immunization rates are important indicators for accreditation.

There are four key issues affecting vaccines that should be part of every contract negotiation for pediatricians, whether at the solo-provider or the large- group level.

1. The new codes. Managed care has challenged most physicians to react to change after change, and charging for vaccine services given in the office has certainly been no exception. Not long ago we used a global code to bill for vaccines that usually included both the cost of the product and some reimbursement for giving it.

Next came new codes for the administration onlyin 1999 code 90471 (immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections and/or intranasal or oral administration]; one vaccine [single or combination vaccine/toxoid]) for the first vaccine, and 90472 (each additional vaccine) for two or more vaccines. There were new codes too for each separate vaccine product, and in some cases for a different dose or age group. One then bills using both codes to capture the costs of the product and the expense of the administration. For CPT 2000 the second code (90472) was revised at the request of the AAP so that now it can be used for the second and each subsequent vaccine.

2. Relative value units. Coding is just one issue, as many providers who have checked their reimbursements and denials know. How should one value the administration codes, and what should we expect the payers to pay? All new and many revised codes go from the CPT process to the AMA for a recommended value by the RVS Update Committee (RUC). This was done with the vaccine administration codes, and a relative work value was recommended and forwarded to HCFA for inclusion in its Medicare fee schedule for the year 2000. When codes appear here and are given a relative value, many payers will adopt the value if they use the RBRVS for payments to providers of all types, not just Medicare.

The vaccine administration codes appeared in the Medicare fee schedule, but without a relative value. The AAP is discussing with HCFA the implications of its omission including the potential dismantling of the immunization system now in place. HCFAs argument for the intended omission of an RVU has to do with its use of a HCPCS code already in place for the administration of the influenza and pneumococcal vaccines to Medicare recipients, as well as the perception that there is no real physician work in the administration codes.

3. Understand administration codes and E/M services. Many questions arise about using the administration codes along with a separate evaluation and management (E/M) service. Certainly there is a good case for using both the product codes with the administration codes when vaccines are given as part of a preventive medicine visit. During the visit, the code for the preventive medicine visit covers the taking of the immunization history and the ordering of the vaccines. From this point on, the work and expense are covered by the vaccine codes as follows:

The vaccine administration codes include the physician work of discussing the vaccine risks and benefits and the care for any complications that happen subsequently (such as a phone call back to the office) that is not separately billed. The expense portion of the code involves the nurse time to give and document the procedure as well as the materials like the needles and syringes, alcohol swab and adhesive bandage. The actual cost of the vaccine is billed with the specific vaccine product code.

4. Nurse visit code allowed? What if a child comes in just to see the nurse to catch up on immunizations? Can one use the nurse visit code 99211 along with the vaccine codes for the administration and the product? I think the physician can use both the 99211 and the 90471-90472. The 99211 allows the capture of the administrative time and expense to register the patient, generate the encounter form, pull the record, and escort the patient to the room. In addition, most offices instruct the nurse by protocol to ask about any current illness or about prior reactions that might modify the vaccine schedule, as well as take vital signs. The nurse then determines the vaccines needed. All of these processes incur expenseyou must decide if you want to attempt some recovery or just write it off.

In the above scenario, which ICD-9 code should you link to the 99211? Unlike the preventive medicine visit, where one usually uses the V code for the visit (V20.2), here one probably should use the V code for the specific vaccine(s). Some payers will not reimburse the V codes. Others may want a -25 modifier (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) attached to the E/M services code if 90471-90472 are used. (ICD-10 will eventually eliminate V codes.)

Note: For more on vaccine administration codes, see the article Correctly Code Immunization-Only Visits with 90471/90472, Not Nurse Only Visits on page 9 of the February 2000 issue of Pediatric Coding Alert.