Pediatric Coding Alert

Question: What modifier should I use for multiple vaccination administration codes CPT 90466 and 90472? Insurers are denying administration services after the first two.


Texas Subscriber

Answer: Unfortunately, insurers are not following CPT's rules regarding +90466 (Immunization administration under 8 years of age [includes percutaneous, intradermal, subcutaneous, or intramuscular injections] when the physician counsels the patient and/or 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]).

Because 90466 and 90472 are add-on codes, they do not require a modifier, according to CPT and the National Physician Fee Schedule.

Right way: You should report one unit of the code per each additional injection, such as 90472 with three units. Pediatric practices in California and Ohio report no problems with this issue and encourage you to appeal the rejections without adding modifiers.
 
But a slew of payers require modifier 51 (Multiple procedures) or 76 (Repeat procedure by same physician) on multiple 90466 and/or 90472 submissions.

Blue Cross/Blue Shield carrier CareFirst (Maryland, Delaware and the District of Columbia) wanted modifier 51 with 90472 and reduced the procedure's fee by 50 percent. After the American Academy of Pediatrics contacted the carrier, CareFirst apologized and published a correction, noting that modifier 51 is not required for 90472.

Guardian (Texas) offers contradictory advice. When a nurse administers three or more immunizations without pediatrician counseling, the carrier states you may report 90472 "with a quantity of two (or more times depending on the number of immunizations) or [90472] may be billed on two separate lines with modifier 76."

Lesson learned: Although add-on vaccine administration codes do not technically require a modifier, insurers may impose additional requirements that you should challenge or follow, provided you obtain the written policy.