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Pediatric Coding Alert

READER QUESTIONS:

Simple Tool Fights Code Nonrecognition

Published on Sat Aug 20, 2005

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.

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