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Primary Care Coding Alert

Reader Question:

Payer Policy Trumps Coding Guidelines

Published on Wed Jun 15, 2011

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 SubscriberAnswer: 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 [...]
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