Pediatric Coding Alert

Question: We just got a denial from Blue Cross Blue Shield (BCBS) for using modifier 59 on vaccine administration code 90471. Is there a reason why this modifier is invalid when we bill 99215-25, 90670, and 90471-59?

Georgia Subscriber

Answer: The answer to this question can be found in the detailed description for modifier 59 (Distinct procedural service) found in CPT^® Appendix A. First, you were correct 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) and not 59 to evaluation and management (E/M) code 99215 (Office or other outpatient visit for the evaluation and management of an established patient …), as the description explicitly states that “Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.”

However, appending modifier 59 to 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)) when your provider administers a vaccine such as 90670 (Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use) is incorrect, as Appendix A also specifies that the modifier is used “to identify procedures/services … that are not normally reported together.”

So, simply put, immunization administration as described by 90471 always goes together with a vaccine code such as 90670, making the addition of modifier 59 unnecessary under normal circumstances such as these.