Pediatric Coding Alert

Submit 90465-90468 to NJ MCOs, not to Georgia Medicaid

More insurers are accepting the CPT 2005-introduced pediatric counseling codes - at least if you live in the right state.

Experts Advise Rejecting Nonrecognition

Locale seems to be the key in determining who's winning the battle on coverage for 90465-90468 (Immunization administration under age 8 years ... when the physician counsels the patient/family ...). New Jersey managed-care organizations (MCOs), including Unicare, Aetna, and Cigna, are all paying on 90465-90468, says Richard Lander, MD, FAAP, a pediatrician at Essex-Morris Pediatric Group in Livingston, N.J. "We only had trouble with Horizon of New Jersey and that was due to a computer glitch."

Caveat: Just because an MCO in New Jersey accepts 90465-90468 doesn't mean the same insurance company in Illinois will. "Even though the national plans accept the new codes, local MCOs - for instance, Cigna of Illinois - have some discretion over coverage," Lander says.

AAP experts, however, still recommend that you report the new pediatric-specific immunization administration codes even to insurers that don't recognize 90465-90468. "Call the insurer and tell the representative that CPT contains 90465-90468 and that HIPAA requires the payer to accept the CPT code set ," Lander says.

Medicaid May Pay Admin Another Way

But some insurers are still playing hardball. Consistent 90465-90468 denials from Georgia Medicaid prompted one coder to question the carrier's practice, writes Mary Lou Ciulla, account manager at Medical Account Management Solutions in Marietta, Ga. "Medicaid does not recognize these new codes," Medicaid coordinator Leticia Mayfield told Ciulla.

Reason: "The provider receives vaccines free through the Vaccine For Children (VFC) program. Therefore, Medicaid already considers the current reimbursement the provider receives for vaccines an admin fee," Mayfield said.

Translation: "When billing for vaccine administration under the Health Check program, continue to report the appropriate vaccine codes with POS [place of service] 99, and you should be reimbursed for the administration," states the Georgia Chapter of the American Academy of Pediatrics on its Coding and Compliance Web page. "Medicaid does not recognize codes 90471 to 90474 or 90465 to 90468."

Lesson learned: Research new codes before you start to use them, Ciulla says. Know local variations and implementation time tables.