Pediatric Coding Alert

Question: When we bill 90466 or 90472 more than once, insurers deny the additional submissions as duplicate charges. Do you have any suggestions on how to bill these codes in multiples and receive payment without appealing?


Texas Subscriber
Answer: Unfortunately, insurance company system edits may be at the root of your problem. These software glitches may incorrectly trigger denials for duplicate charges of add-on immunization administration codes, such as +90466 (Immunization administration under 8 years of age [includes percutaneous, intradermal, subcutaneous, or intramuscular injections] when the physician counsels the patient/family; each additional injection [single or combination vaccine/toxoid], per day [list separately in addition to code for primary procedure]) and +90472 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]).

Insurers may have overlooked entering these codes as allowing multiple billings. So you may have to work with providers to correct these errors.

Some companies are working to fix duplicate denials for multiple subsequent vaccine administrations. For instance, Carefirst BlueCross Blue Shield, which serves Maryland, Delaware, Washington, D.C., and portions of Virginia, recommends contacting your provider representative to have claims reprocessed and notes, "Claims with multiple submissions of these codes that are processed on and after [April 16, 2005] will be adjudicated appropriately."

Tip: You can prevent multiple submission denials for 90466 and/or 90472 if you learn your payer's billing method. Some insurers, such as BCBS of Tennessee, prefer that you use units to indicate "the number of subsequent vaccinations administered."

Although using units simplifies claim forms, it doesn't allow you to link each additional vaccine administration code with its vaccine product code and diagnosis. Itemizing your form may help the insurer's system process each vaccine grouping, rather than assuming the administration charges are duplicates.
 
In fact, BCBS of Massachusetts recommends either method. Here's how these methods compare for a 6-month-old who receives DTaP, Hib, PCV at an established patient preventive-medicine service in which the pediatrician counsels the parent regarding vaccines.