Pediatric Coding Alert

Some payers suggest using 90471-90472, not 90465-90466

You've done everything you should to implement the new immunization injection administration codes - educate staff on their age and counseling requirements, add them on your superbill, start reporting them - but your speedy actions produce denials.

Reason: Several private payers have delayed implementing CPT 90465 (Immunization administration under 8 years of age [includes percutaneous, intradermal, subcutaneous, or intramuscular injections] when the physician counsels the patient/family; first injection [single or combination vaccine/toxoid], per day) and +90466 (... each additional injection [single or combination vaccine/toxoid], per day [list separately in addition to code for primary procedure]).

Here's how you can avoid a pile of rejections.

Revert to 90471-2 Until Payer Activates 90465-6

Until an insurer accepts the new vaccine injection administration codes (90465-90466), you will have to use the old codes (90471, Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]; +90472, ... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]), says Bonnie Palmer, billing manager at Tots N Teens Health Associates in Hoffman Estates, Ill. "Report 90471-90472 instead of 90465 and 90466 to payers that have not activated the CPT 2005 codes."

Even though HIPAA requires insurance companies to accept a universal coding system, not all payers are activating CPT 2005 codes on time. "We started using the new shot administration codes 90465 and 90466 as of Jan. 1, 2005," says Chantal Senra, coding specialist at Dr. Lori McAuliffe in St. Petersburg, Fla. Cigna will not load the new codes until May and will not make 90465-90466 retroactive to Jan. 1.

Translation: If a pediatrician documents pre-vaccine counseling on a child under 7 years of age and reports 90465-90466, Cigna will reject the administration
service. "You will receive a denial for an invalid code," Palmer says.

Best practice: For payers that delay implementation, get the directive in writing. "That way, you can show why you used the old vaccine administration codes when the new codes more accurately describe the pediatrician's services," Palmer says.

Delay Filing 90465-90466 to These Insurers

Several insurance companies have not loaded the new vaccine shot codes (90465-90466) in their systems. For these payers, insurance representatives suggest offices use the old codes (90471-90472) for at least a few months,  Palmer says.

Bottom line: If you use 90465-90466, you will receive denials for invalid codes from these companies (check with your carrier for specifics):