Primary Care Coding Alert

Question: Our Medicaid carrier refuses to accept the new vaccination codes, but we know it's correct coding to report them. Should we report 90460-90461 to Medicaid and appeal any denials?

Oregon Subscriber

Answer: You should not go against your local payer's advice -- if your Medicaid carrier will not accept the new codes, then you should report only the codes they advise.

Example: Oregon's state Department of Medical Assistance Programs office instructs on its Web site that practices should continue reporting immunizations the same way they did in 2010, despite the new codes. "Do not use the new CPT® codes (90460-90461) available for children's immunizations," the payer's site instructs. Instead, Oregon's Department of Human Services notes that practices should "continue to bill immunizations with the specific vaccine administered and add modifier SL or 26." (See https://apps.state.or.us/cf1/OHP/OHPadmin/files/pm0111.pdf for the complete directive).

In other cases, some state agencies may choose to pay one of the new codes but not the other. The Tennessee Vaccines for Children (VFC) Program maintains its own rules for reporting immunizations, and does not include recognition of new code 90461.

"Providers are encouraged to use the new code 90460 for the administration of a vaccine under the VFC program," the organization's Web site notes. "If code 90461 is used for a vaccine with multiple antigens or components, it should be given a $0 value for a child covered under the VFC program. This applies to both Medicaid-enrolled VFCentitled children as well as non-Medicaid-enrolled VFCentitled children."

These individual state Medicaid inconsistencies make providing immunizations for children on the Medicaid Vaccines for Children program difficult. However, this struggle is nothing new for physician offices. Given Medicare guidelines to the state programs, it is unlikely your state will be adopting the new 90460-90461 series at this time.