Pediatric Coding Alert

Don't hesitate to check with your payer before submitting your immunization claims.

Just a few months ago, you got the news that CPT would be deleting the old immunization administration codes 90465-90468 and debuting immunization administration by component "with counseling" codes 90460-90461. The new codes took effect on Jan. 1 and initially it looked like processes were working smoothly -- until it came time for claims submissions. Then the denials began to arrive, puzzling practices that submitted what they thought were clean claims.

Local carriers may have hit a few speed bumps while processing the first of the vaccine administration claims, but are attempting to get their systems rolling smoothly as February closes out for codes 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component) and +90461 (... each additional vaccine/toxoid component (List separately in addition to code for primary procedure). Following are the answers to several questions -- straight from the payers themselves -- which may help you ensure that your claims go through smoothly.

Question 1: Can we report 90461 more than once for a patient on the same date of service? If so, should we append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to it?

Answer: According to United Health Care, you can report multiple units of 90461 on the same date of service, but you can hold the modifier.

"Applying modifier 25 to 90461 is not required in order to prevent this code from being denied for billing multiple times on the same date of service," UHC notes in a "frequently asked questions" page on its Web site. "When 90461 is billed multiple times for the same date of service, you may either bill 90461 on one claim line with the total number of units reported on a single line or on separate claim lines with one unit reported on each separate line."

Resource: You can read UHC's complete FAQs at www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies/Immunization_FAQs.pdf.

Question 2: Can we still bill 90460-90461 if the physician does not perform counseling? If that is the case, should we append modifier 52 (Reduced services) to the vaccine code to denote that no counseling took place?

Answer: No, you should not report codes 90460-90461 if the physician or other qualified healthcare professional didn't perform vaccine counseling -- appending modifier 52 will not help your chances of making this the correct code.

Blue Cross Blue Shield of NC has a directive on its Web site stating, "Immunization administration codes 90471-90474 will remain unchanged and will continue to be reported for patients 19 years and older, or if there is no counseling performed on the patient or the healthcare professional counseling does not meet state requirements for an "other qualified healthcare professional." You can read this policy at www.bcbsnc.com/content/providers/important-news/jan14-2011.htm.

Bottom line: If your practitioner administers the vaccine without counseling, select the most appropriate code from the 90471-90474 (Immunization administration...) range, and forego reporting one of the new codes.

Question 3: My insurer told me that the new codes are billed "per component" rather than per injection. Can you explain what "per component" means?

Answer: "A component refers to each antigen in a vaccine that prevents disease(s) caused by one organism," according to a coding bulletin on Neighborhood Health Plan's Web site (www.nhp.org/PDFs/Providers/NoticeNewCodesVaccines.pdf).

For example: A pediatrician counsels a mother on vaccine risks and benefits prior to giving the patient Pediarix, which has five components: DTaP-HepBIPV. The diphtheria, tetanus toxoids, acellular pertussis each count as one component, plus Hepatitis B and inactivated polio virus each count as one. For the vaccine administration with counseling on the components included in Pediarix, you'll report one unit of 90460 and four units of +90461.

Question 4: Our Medicaid carrier refuses to accept the new vaccination codes, but we know it's correct coding to report them. Should we report 90460-90461 to Medicaid and appeal any denials?

Answer: You should not go against your local payer's advice -- if your Medicaid carrier will not accept the new codes, then you should report only the codes they advise.

For instance: Oregon's state Department of Medical Assistance Programs office instructs on its Web site that practices should continue reporting immunizations the same way they did last year, despite the new codes. "Do not use the new CPT codes (90460-90461) available for children's immunizations," the payer's site instructs. Instead, Oregon's Department of Human Services notes that practices should "continue to bill immunizations with the specific vaccine administered and add modifier SL or 26." (See https://apps.state.or.us/cf1/OHP/OHPadmin/files/pm0111.pdf for the complete directive).

In other cases, some state agencies may choose to pay one of the new codes but not the other. The Tennessee Vaccines for Children (VFC) Program maintains its own rules for reporting immunizations, and does not include recognition of new code 90461. "Providers are encouraged to use the new code 90460 for the administration of a vaccine under the VFC program," the organization's Web site notes. "If code 90461 is used for a vaccine with multiple antigens or components, it should be given a $0 value for a child covered under the VFC program. This applies to both Medicaid-enrolled VFC-entitled children as well as non-Medicaid-enrolled VFC-entitled children."

You can read the statement in its entirety at www.bcbst.com/providers/bluecare-tenncareselect/VFC_Vax_Admin_CPT_guidance.pdf.

These individual state Medicaid inconsistencies make providing immunizations for children on the Medicaid Vaccine for Children program difficult. However, this struggle is nothing new. Given Medicare guidelines to the state programs, it is unlikely your state will be adopting the new 90460-90461 series at this time.