msonger
Networker
As you know the new codes 90460/61 came into effect this past year. These new codes indicate counseling was provided by the provider/MD/NP. SC Medicaid released a memo stating that these new codes would be covered when billed with vaccinations. The other codes 90471 were reduced in payment since they only reflect the vaccination and NO counseling component. SC Medicaid payors have interpreted that for children 18 and under, we can only use codes 90460/61 to indicate vaccines were administered. I feel this is inappropriate coding and that I would be paid for a level of care that we did not provide. How do I appeal to this payor and their CPC that this is inappropriate. OR is it?
I am not coding the 90460 at this time and my 90471 codes are being rejected because they want me to send it as 90460.....see the below email correspondence....
Michelle, Here is the explanation from our coder in Charleston.
From: Hlavac, Carolyn
Sent: Thursday, August 25, 2011 9:09 AM
To: Steele, Kaye
Subject: RE: CPT 90460 vs. 90471 pediatric vaccine administration vs. counseling
The bulletin is for Medicaid FFS, not from Select Health. We are requiring that the RHC/FQHC bill with the vaccine and the appropriate admin codes for the VAFAC program and have required that since last year when DHHS began requiring the vaccine product be billed along with the administration code.
Our configuration is set that way as well. If they do not bill the vaccine product then they will not be paid for the vaccine administration. We questioned DHHS at the time this bulletin was released about the administration codes specifically and they told us that 90460-90461 were for use on children and 90471-90474 were to be used for adult vaccine administration. That is why there is a difference in the reimbursement. The 90471-90474 now reimburses the amount that 96372 reimbursed in 2010 for adult vaccine administration. It was $4 in 2010 for adult vaccine admin and with the reductions is now $3.72 as of 7/11/11. The counseling is not mentioned in any of the bulletins about this subject. The components are specifically mentioned and are not to be considered when utilizing these codes.
Thanks
Carolyn
From: Steele, Kaye
Sent: Wednesday, August 24, 2011 3:08 PM
To: Hlavac, Carolyn
Subject: FW: cpt 90460 vs 90471 pediatric vaccine administration vs counseling
Carolyn, Do you know what our interpretation is for FHQHC.
Kaye Steele
Network Management Representative
Select Health of South Carolina
803-359-6112 - office
803-348-5792 - cell
803-359-7177 - fax
www.selecthealthofsc.com
Mission: We help people get care, stay well and build healthy communities
--------------------------------------------------------------------------------
From: Michelle Newman-Songer [msonger@sumterfhc.com]
Sent: Wednesday, August 24, 2011 12:47 PM
To: Steele, Kaye; Michelle Newman-Songer
Cc: Michelle Newman-Songer; Debbie Prescott; Angie Windham
Subject: cpt 90460 vs 90471 pediatric vaccine administration vs counseling
Please know that this memo specifically states that it does not affect FQHCs.
90471 is still on the Medicaid fee schedule. My interpretation is that SC Medicaid's attempt was to notify providers that 90471 fee schedule was reduced since it did not include the verbal counseling. Also that in order to be eligible for the $12.61 a provider must provide the verbal counseling 90460/90461. In regards to the unit of service, my interpretation is that Medicaid is limiting it to one 90460 and two 90461 instead of per component as the cpt reads.
I have done some research on the AAPC website, and the certified coders agree that counseling must be done and documented to bill for it. Otherwise, admin only codes should be used 90471/72. I do not feel this memo indicates that Medicaid wants us to stop coding 90471 correctly. However, Medicaid is attempting to force providers to perform one on one counseling and document it to be paid for it with cpt 90460.
According to Medicaid fee schedule eff 7/1/11, here are the allowed amounts for these cpts:
90460 $12.61
90461 $12.61
90470 $3.88
90471 $3.72
90472 $3.72
90473 $3.72
90474 $3.72
I am not coding the 90460 at this time and my 90471 codes are being rejected because they want me to send it as 90460.....see the below email correspondence....
Michelle, Here is the explanation from our coder in Charleston.
From: Hlavac, Carolyn
Sent: Thursday, August 25, 2011 9:09 AM
To: Steele, Kaye
Subject: RE: CPT 90460 vs. 90471 pediatric vaccine administration vs. counseling
The bulletin is for Medicaid FFS, not from Select Health. We are requiring that the RHC/FQHC bill with the vaccine and the appropriate admin codes for the VAFAC program and have required that since last year when DHHS began requiring the vaccine product be billed along with the administration code.
Our configuration is set that way as well. If they do not bill the vaccine product then they will not be paid for the vaccine administration. We questioned DHHS at the time this bulletin was released about the administration codes specifically and they told us that 90460-90461 were for use on children and 90471-90474 were to be used for adult vaccine administration. That is why there is a difference in the reimbursement. The 90471-90474 now reimburses the amount that 96372 reimbursed in 2010 for adult vaccine administration. It was $4 in 2010 for adult vaccine admin and with the reductions is now $3.72 as of 7/11/11. The counseling is not mentioned in any of the bulletins about this subject. The components are specifically mentioned and are not to be considered when utilizing these codes.
Thanks
Carolyn
From: Steele, Kaye
Sent: Wednesday, August 24, 2011 3:08 PM
To: Hlavac, Carolyn
Subject: FW: cpt 90460 vs 90471 pediatric vaccine administration vs counseling
Carolyn, Do you know what our interpretation is for FHQHC.
Kaye Steele
Network Management Representative
Select Health of South Carolina
803-359-6112 - office
803-348-5792 - cell
803-359-7177 - fax
www.selecthealthofsc.com
Mission: We help people get care, stay well and build healthy communities
--------------------------------------------------------------------------------
From: Michelle Newman-Songer [msonger@sumterfhc.com]
Sent: Wednesday, August 24, 2011 12:47 PM
To: Steele, Kaye; Michelle Newman-Songer
Cc: Michelle Newman-Songer; Debbie Prescott; Angie Windham
Subject: cpt 90460 vs 90471 pediatric vaccine administration vs counseling
Please know that this memo specifically states that it does not affect FQHCs.
90471 is still on the Medicaid fee schedule. My interpretation is that SC Medicaid's attempt was to notify providers that 90471 fee schedule was reduced since it did not include the verbal counseling. Also that in order to be eligible for the $12.61 a provider must provide the verbal counseling 90460/90461. In regards to the unit of service, my interpretation is that Medicaid is limiting it to one 90460 and two 90461 instead of per component as the cpt reads.
I have done some research on the AAPC website, and the certified coders agree that counseling must be done and documented to bill for it. Otherwise, admin only codes should be used 90471/72. I do not feel this memo indicates that Medicaid wants us to stop coding 90471 correctly. However, Medicaid is attempting to force providers to perform one on one counseling and document it to be paid for it with cpt 90460.
According to Medicaid fee schedule eff 7/1/11, here are the allowed amounts for these cpts:
90460 $12.61
90461 $12.61
90470 $3.88
90471 $3.72
90472 $3.72
90473 $3.72
90474 $3.72