Pediatric Coding Alert

Question: An insurer that we frequently bill rejects new vaccine CPT 90714 because the company's system does not recognize the code. Should I appeal the denials?


Vermont Subscriber
Answer: Absolutely. HIPAA requires insurance companies to accept a universal code set and to recognize those codes by their CPT or ICD-9 effective dates. The government implemented HIPAA laws specifically to stop insurers from playing games with individual codes and activation dates.

Good idea: Double-check the payer's 90714 (Tetanus and diphtheria toxoids [Td] adsorbed, preservative-free, for use in individuals 7 years or older, for intramuscular use) denial reason. Acceptable rejection reasons for the preservative-free Td vaccine, DECAVAC, include the insurer:
  not paying for the code until the code's effective date, July 1, 2005. Some companies accepted 90714 prior to its HIPAA effective date.
  recognizing the code but not reimbursing the service or procedure. You should, however, appeal claim rejections due to the insurer stating:  the code is not in the system (after July 1, 2005)
  it does not recognize the code.

Example: Some insurers deny new vaccination administration codes 90465-90468 (Immunization administration under 8 years of age ... when the physician counsels the patient/family ...) because the company does not recognize the codes. But CPT made these codes effective on claims starting Jan. 1, 2005. Therefore, you should appeal the rejection with a preprinted form letter stating that CPT contains 90465-90468 and that HIPAA requires the payer to accept the CPT code set.

Bottom line: HIPAA makes code non-entry and non-recognition illegal. Tool: You can register a complaint against the violating insurance company by completing a free on-line form. To fight the insurer, go to http://www.ama-assn.org/ama/pub/category/11132.html.