Pediatric Coding Alert

Combination vaccines are growing by leaps and bounds, and this has some pediatricians worried. Theres no way that a pediatric office can carry the vast number of combinations, says Barbara Grogg, office manager for Children and Adolescent Medical Services of Tulsa, OK. Youd have to have a walk-in refrigerator. So, some pediatricians are using individual vaccines instead.

Whether you are using state-provided vaccines or purchased vaccines, you may be running into a problem with some insurance companies in terms of individual vs. combination immunizations. You may give immunizations separately even though a combination is available, perhaps because of age requirements, or because the child is catching up on immunizations, or because, as Grogg says, you no longer have room in your refrigerator for all the new combination vaccines. You submit the claim, but the explanation of benefits (EOB) comes back indicating that you gave the combination vaccine instead.

Its happening in Oklahoma, says Grogg. And its not right. If theyre given individually, they shouldnt be paid as if it were a combination. First of all, if separate vaccines are recorded as a combination vaccine, its going to be impossible to track the side effects of the combination vaccines. Another reason, states Grogg, is that CPT gives specific codes for each vaccine. You need to stick to the specifics, she says. And, last but certainly not least, if you are in a universal state, and the insurance company is forcing the combined codes, you are losing out on administration fees.

Combined vaccines are paid at a much lower rate than individual vaccines given separately which, of course, is why insurance companies prefer the combined codes.

Particularly troublesome is 90748, the CPT code for the new combination vaccine of hepatitis B and Haemophilus influenzae Type B (HIB). Hepatitis B is 90744, and HIB is 90737. Grogg has found that when her practice gives the two separate vaccines, Prudential and United HealthCare are changing these two codes to one: 90748. So Grogg has devised a response to insurance companies that conduct such bundling: she writes the provider relations person (not the claims person) to tell them specifically what codes should have been used, and why. The only way to accurately track and code for immunizations is to use the exact code that pertains to the immunization given, her letter says. The insurance companies should not bundle and recode when specific codes for the specific immunizations are available. They should reimburse for the specific immunizations given.

Another problem arises when an insurance company tries to reimburse for the wrongbut less expensivevaccines. Take DTAP and HIB, which must be given separately under 15 months of age. Some companies wanted to reimburse use for DTP/HIB, Grogg recalls. Were using DTaP and HIB, which has fewer side effects. But, the insurance company was paying as if the doctor was using the older DTP/HIB vaccine, instead of the newer, but separate, DTaP and HIB. Grogg had pulled all DTP codes from the computer so no one could even say they used DTP, she says. We dont have it in the office, and we wont have it in the office. Grogg certainly didnt want it in their records that they had given DTP when they hadnt. One physician was so upset by what the insurance companies were doing that he wrote a letter to the insurance companies that basically instructed them to notify him in writing if you would like me to use the old combination. The purpose of the notification would be so I can explain to may patients parents that I must use the vaccine with more untoward side effects, the doctor wrote. Every company started reimbursing him correctly, immediately, Grogg says.