Pediatric Coding Alert

Question: Our pediatric practice is receiving denials on 90460/90461. What should we do to correct them?

Rhode Island Subscriber

Answer: Without more information, it is hard to know the specific reason your payer is denying 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered) and +90461 (… each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)).

There are several possibilities, however. The first could be due to your documentation. As the code descriptors state, you will need to demonstrate first that the physician or a qualified healthcare professional (QHP) counseled patients about the vaccine face-to-face, and second that patient received the immunization. If your documentation shows that patients received the immunization without the counseling, you cannot report these codes.

Additionally, you might want to check the ages of the patients receiving the service. If they are over 18, that could be another reason for denial.

A more likely reason may have to do with what other services you are providing to your patients at the same time as the vaccinations. If you are administering them during preventive medicine visits, or any evaluation and management (E/M) visits for that matter, you will have to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M.

That’s because National Correct Coding Initiative (NCCI, or CCI) edits bundle the 90460/90461 codes into all the E/M codes, though as the edits have a modifier indicator of 1, you will be able to override the edit with an appropriate modifier such as 25. Without it, your payer could regard immunizations as bundled into E/M services and will deny them.

Finally, you could try using 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)) or 90473 (Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)) as alternatives to using 90460/+90461 if they better reflect the circumstances of your encounters (i.e. that the patients did not receive counseling).

If the patients did receive counseling and you are still being denied, you will need to challenge the payer on the denial, as the payer may have incorrectly denied the service.