Pediatric Coding Alert

Let staff know about carrier challenges, and prepare a waiver when necessary.

Nearly two years ago, the FDA approved the HPV vaccine Gardasil® for male patients, but many pediatric practices continue to struggle for payment when administering the product to boys. Read on to find out how you can avoid losing money if you offer this relatively new vaccine.

Background: Gardasil® prevents precancerous genital lesions and genital warts due to the human papilloma virus (HPV) types 6, 11, 16, and 18. Initially approved for female patients, the vaccine was extended to male patients as well in October 2009 thanks to an FDA approval announcement. However, despite the FDA's stamp of approval, several insurers are still slow to pay for this vaccine when administered to male patients. Follow these steps to ensure you collect for the vaccines:

1. Check insurer coverage. It may be time-consuming up-front, but you'll save your energy down the road if you confirm male Gardasil® coverage before patients report to your practice. The Web site of Merck (which manufactures the vaccine) advises practices to ask insurers whether they provide coverage for Gardasil®, determine whether any coverage restrictions exist, find out copay and deductible amounts, and check on coverage maximums for the medication (typically administered with the appropriate immunization administration code, such as 90460 or 90471, as well as 90649 (Human Papilloma virus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent], 3 dose schedule, for intramuscular use).

Ideally, your insurer will send you the information in writing. Pallavi Subramanian, RCM manager with Health Prime International, LLC in National Harbor, Md., received a letter from Georgia Medicaid in 2010 indicating that Peach State Health Plan would "accept CPT code 90649 for females AND males, ages 9 to 21 years enrolled in the Georgia Medicaid and Peach Care for Kids programs," the notice indicated.

In cases when payers refuse to cover Gardasil® for male patients, the practice manager should consider writing to the plan's medical director with a copy of the FDA's approval letter (www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm187003.htm), formally requesting the payer to offer coverage for both genders. Although this may not fix your immediate coverage issues, it could help encourage the insurer to offer male Gardasil® payment down the road.

2. Prep a payment waiver form. While most coders are aware of Medicare's "advance beneficiary notices" (ABNs), those aren't required for private payers. However, you can create a similar waiver for your pediatric practice to let patients and their parents know when they might be responsible for payment, particularly in situations such as male Gardasil® vaccines.

"While most plans cover Gardasil® for boys, you should prepare a letter to give to parents whose insurance does not yet cover this vaccine for boys, informing the parents that they would be responsible for the cost as it is not a covered benefit," advises Jeff Winokur, President of Atlantic Health Partners.

The letter, which is a version of an advanced beneficiary notice (ABN), should inform the patient's parents of the expected charge, and you should have them sign it to confirm that they are aware of their potential payment responsibility. See page 75 for a copy of a sample waiver notice that you can offer at your practice.

3. Inform your staff of when the product is non-covered. Your employees--from the receptionists to the nurses--won't know when to extend a payment waiver unless you inform them of which insurers deny male Gardasil® vaccines. Therefore, you should find a way to share this information with staff members.

"I actually taped a piece of paper to the vaccine refrigerator for my nurses that reminds them that Gardasil® isn't covered for boys" when dealing with certain insurers, says Angela Adams, office manager with Oklahoma Pediatric Center. "If the parent still wants it and the patient is under the age of 18, the practice can ask the parent to sign a waiver stating that they will pay for the vaccine, or, if the patient is eligible, the practice can administer a VFC vaccine."