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Primary Care Coding Alert

Pediatric Coding Corner:

Reserve 90465-90468 for Same-Day Counseling, Immunization

Published on Thu Jan 27, 2005

Good news: You'll now receive Medicare shot administration payment

Be careful not to assign new vaccine administration codes when a child who already received family physician- provided prevaccine counseling returns for a shot-only visit.
 
CPT 2005's creation of four immunization administration codes has caused confusion among primary-care coders. In fact, "The American Academy of Pediatrics (AAP) has been so inundated with questions concerning 90465-90468 that the organization is issuing a seven-page supplement addressing the codes," says Richard Tuck, MD, FAAP, a member of the RBRVS review update committee (RUC).
 
Learn the basics on when you should report the codes.

90465-90468 Impose Age, Counseling Requirements

To use the new vaccine administration codes, the encounter must satisfy two requirements. The patient must be under 8 years of age, says Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan. In addition, the family physician (FP) or nonphysician practitioner (NPP) must perform counseling on the vaccination risks and adverse reactions and answer any concerns the parent may have.
 
"The new vaccine administration codes will initially make coding more difficult," Moore says. Not only do you have more codes, but you also have to "distinguish between them based on age, as well as whether or not physician counseling was involved."
 
Idea: Instead of listing all eight codes on your superbill, you may simply include "vaccine admin." The physician can then mark "No counseling" whenever she performs vaccine administration without counseling, says Victoria S. Jackson, president of OMNI Management, a consulting firm in California. Otherwise, the coder should assume the encounter included prevaccine counseling and use the new codes, provided the patient is under 8 years  of age.

FP Must Perform Criteria at Same Encounter

Sometimes, however, patients don't receive the vaccinations at the same visit in which the counseling occurred. "The child may be sick, so the parent may want to delay the injections," Jackson says.
 
Be careful: You may be tempted in this situation to think that you can apply the new vaccine administration codes. At first glance, the scenario may appear to have met 90465-90468's criteria:
 

  • the child is under 8 years of age
     
  • the physician performs prevaccine counseling.

    Hitch: The requirements occur at separate visits. Therefore, you should not use the new immunization administration codes, Tuck says. You must instead report the existing vaccine administration codes: 90471-90474.

    No Additional Payment for 90465-90466

    The AAP intended the new vaccine administration codes to reimburse physicians for prevaccine counseling work in the pediatric population. Medicare, however, assigned the same work values to 90465 and 90466 as to 90471 and 90472. The AAP is appealing for additional 90465-90466 payment.
     
    Payments: Medicare allotted 0.49 relative value units ($18.57 national unadjusted rate) to 90465 - the same amount 90471 contains - and 0.29 RVUs ($10.99 national unadjusted rate) to 90466 and 90472. Codes 90465 and 90471 both contain 0.17 work RVUs. Medicare assigned 0.15 work RVUs to 90466 and 90472.
     
    Good news: Payers have the new codes programmed in their systems and are processing claims with 90465-90468, says Bonnie Palmer, billing manager at Tots N Teens Health Associates in Hoffman Estates, Ill.
     
    Reimbursement hurdle: Unfortunately, Medicare didn't assign any relative value units to the intranasal vaccine codes. CMS feels that patients self-administer intranasal vaccines, so the service involves no physician work. "Obviously, this is a faulty assumption when dealing with children, and the AAP is appealing the decision," Tuck says.

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