Pediatric Coding Alert

Question: We have been using 99401 when counseling for COVID vaccines, and when we also give other shots at the visit and use 90460, I have been adding the 59 modifier on the 90460 to get it to pay and it works for most insurers. Unfortunately, it does not work for Neighborhood Health Plan of Rhode Island. They state that it is the wrong modifier combination. They require a CR modifier on 99401, which we have done, but I am lost as to what else to use on the 90460 to get the 99401 to pay. Is there another modifier that might work?

Rhode Island Subscriber

Answer: As we reported in Pediatric Coding Alert volume 25, number 2, to report counseling for COVID-19 vaccines, you would report a preventive medicine counseling code such as 99401 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes) or 99429 (Unlisted preventive medicine service) depending on individual payer preference. Additionally, as the Neighborhood Health Plan of Rhode Island administers Medicaid plans, you would add the CR (Catastrophe/disaster related) modifier to waive Medicare payments on the 99401 during the COVID-19 public health emergence (PHE).

So, you have correctly billed 99401-CR for the COVID-19 vaccine counseling.

But the issue here is the use of the 59 (Distinct procedural service) modifier on the 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered) for your provider’s separate administration and counseling of the non-COVID vaccines. As the HMO is requiring a Medicare modifier on the 99401, it could be that they require one of Medicare’s X{ESPU} modifiers on the 90460.

If this is the case, then XU (Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service) may be the correct modifier to use in this situation. But you should absolutely check with the payer beforehand before resubmitting the claim.

And don’t forget: You’ll add Z71.85 (Encounter for immunization safety counseling) to the 99401 or 99429 for “counseling of a patient or caregiver regarding the safety of a vaccine” per ICD-10 guidelines.