Pediatric Coding Alert

It is clear that the new vaccine administration codes (90471 for one vaccine, and 90472 for two or more), which were supposed to help pediatricians by giving them a way to bill for administration, are causing a tremendous problem for many practices. The biggest problem is the two or more. If, say, you charge $15 to administer one vaccine, and $30 to administer two or more, what happens if you have to administer three vaccinesor more? And this, of course, is assuming that the managed care company will pay you the $15 or $30 you have attached to those codes on your fee schedule. What is actually happening is that many pediatricians, who give more multiple immunizations by far than any other specialty, are losing money because of these new codes.

But next years CPT will have a solution. Instead of being for two or more vaccines, the second code will be for each subsequent vaccination, says Charles J. Schulte, III, MD, FAAP, the American Academy of Pediatrics representative on the American Medical Associations CPT coding committee. The second code has already been approved, says Schulte, who practices in Sterling, VA. This, at least, will make it possible to bill for each vaccine you draw down.

Also good newsit is expected that relative value units (RVUs) will finally be assigned to the two new codes (remember, one will be for one vaccine, and one will be for each subsequent vaccine). There will be an RVU for each code, says Schulte. This will help pediatricians determine what to charge. And more to the point, the existence of an RVU will be guidance to insurance companies on what they should pay.

In the March issue of PCA, one practice was reported as using units to charge for administration of more than two vaccinations. This strategy is working well: One managed care company is paying $5 for one shot, $9 for two shots, and $12 for three shots (not even close to the $15 per shot on the practices fee schedule, but still there is extra reimbursement for more than two vaccines).

However, using units for CPT 90472 is problematic, since CPT specifically states that the code is for two or more single or combination vaccines/toxoids. The use of units is not compatible with the language thats in CPT, says Peter Rappo, MD, FAAP, chairperson of the AAP Committee on Practice and Ambulatory Medicine. I think this could be very difficult, says Rappo, who practices in Brockton, MA. But Schulte disagrees. If a practice has a local agreement with payers, using units is okay, he says.

The Universal State Problem

However, the new verbiage wont solve another problem practices are having. Rappo, for example, isnt even using the new administration codes because they make it impossible to put down all of the vaccine product codes. This is because Massachusetts, where Rappo practices, pays for all vaccines. Were a universal purchasing state, he explains. That means we cant bill for the vaccines themselves and, therefore, we cant put the product codes down, he says. None of the new detailed vaccine product codes can be used along with the administration codes in universal states, or the datawhich immunizations are being givenwould be lost. And insurers very much want that data, because that is one of the ways they demonstrate to the National Committee on Quality Assurance, which accredits HMOs, the quality of their pediatric care. If we were to use the administration codes, the data would get lost, explains Rappo. So were dragging our feet on it. Since the payers are, too, he says, this works out well. But the foot-dragging cant go on forever.

One solution for pediatricians in universal states who want to use the administration codes is to bill for the product code as well, but to put a zero charge next to it. This way the data gets transmitted, but you are not billing for something you havent done (you didnt purchase a vaccine, the state gave it to you). The only problem with this solution is that some managed care computer systems will automatically reject a code with a zero charge; that is a system safeguard to prevent people from making posting errors, Schulte explains. So some practices are charging one cent for those vaccines. This gets through the system, and gets the data through. Theyre just hoping that the companies dont turn around and ask for those pennies back, says Schulte, half-joking.

Until the Year 2000

Until the new subsequent administration verbiage kicks in next year, pediatriciansregardless of whether theyre in universal statesstill need to determine how to be reimbursed for vaccine administration. John Canning, president of the Physicians Computer Company in Winooski, VT, believes in the units solution. He works with pediatricians daily at his firm, which specializes in developing billing systems for pediatricians. And Canning believes that units should be used for vaccine administration until next years new codes solve that part of the problem. The CPT book doesnt say to use units, and it doesnt say not to, says Canning.

There are many costs associated with administering a vaccine above and beyond the cost of pulling a chart and putting a patient in an exam room, he says. First of all, there is the 15-month-old child who doesnt want to be vaccinated. Have you ever watched several nurses, a parent, and a doctor struggle with a 15-month-old? he asks rhetorically.

In addition to the actual administration of the vaccine, the pediatrician has many other costs, notes Canning. Someone has to prepare each vaccine; each individual or combination vaccine requires its own syringe. Vaccine storage is complex. Also, there are the rules and paperwork associated with the Vaccines for Children program. Pediatricians need to be fairly compensated for this, he opines.