Wiki Vaccine administration coding & billing

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PayalP123

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Hi, We are a teaching hospital and have an Independent clinic inside the hospital. We are being denied the administration code 90471 when billed with 99213 & the actual vaccine code. For Example : coded 99213 -25 with 90471-59 90, 90686 . we received
payment for 99213 & 90686, but 90471 administration is being denied stating it was not billed with the correct base procedure code. Can someone please help?
Administration code 90471 and vaccine is 90686 with office visit 99213-25 . I cant figure out what i missed here. All my administration code 90471 for this Independent clinic is being denied. Please advise. Thank you.
 
If this is for a Medicare patient then you would need to use G0008 instead of 90471 - that could be the problem. If it's not a Medicare patient, then you may need to contact the payer and find out if they have a specific policy on how they require this to be billed, or if perhaps the code is being denied in error.
 
thomas7331 said:
If this is for a Medicare patient then you would need to use G0008 instead of 90471 - that could be the problem. If it's not a Medicare patient, then you may need to contact the payer and find out if they have a specific policy on how they require this to be billed, or if perhaps the code is being denied in error.
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These are not Mcare patients so i will check with the Payer now. Thank you for your help.
 
You cannot bill for an E/M code and immunizations at the same time UNLESS the E/M code is truly for something else. We bill for immunizations and TB risk assessments all the time, together, using a 99211 for the TB risk assessment. You don't need a modifier 25 for that. If the only thing they are being seen for is immunizations then you can't bill for anything else. The 99213 will always be denied. If you are getting denied for the admin fee (90471) and getting paid for the 99213 then that is all you will get paid for. It is one or the other. Not both, unfortunately. So, we give out tons of immunizations and we only bill for the shot and the admin fee.
 
I guess, what I should really be asking, is why are you also billing for a 99213? Also, who are you billing this to? In California, where I am, Medi-Cal (medicaid) never pays for the admin fee (90471). It is not in their fee schedule and is just not covered. But if it's for a private insurance, then it should get paid.
 
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I have a question on administration codes for Tdap in the adults. I know with pediatric patients you can bill 3 administration codes for giving a tdap, but can you do the same for an adult?
 
nickel said:
I have a question on administration codes for Tdap in the adults. I know with pediatric patients you can bill 3 administration codes for giving a tdap, but can you do the same for an adult?
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No.... you are probably using the under 18 with counseling codes- 90460, 90461 x2 for TDaP. For adults, you can only use 90471 once. 90471 is a PER INJECTION and not per TOXOID/component.

Also, to comment on the other questions... Medicare and MA will not pay for the 90471 codes. Flu gets G0008. Pneumo G0009. HepB G0010. No need for modifier on the admin code itself. We use 25 modifier on the office visit, assuming patient was not presenting for immunization only.
 
Will medicaid not pay for 90460 and 90471? I am getting alot of denied due to Claim has been denied on 02/24/2023 cpt 90460 as Invalid FQHC/RHC/HIS claim -Missing/incomplete/invalid procedure codes. We are an RHC Clinic- I was told we can bill for the admin fee of these but it wont go through. Thoughts? Thank you
 
Mperkes72 said:
Will medicaid not pay for 90460 and 90471? I am getting alot of denied due to Claim has been denied on 02/24/2023 cpt 90460 as Invalid FQHC/RHC/HIS claim -Missing/incomplete/invalid procedure codes. We are an RHC Clinic- I was told we can bill for the admin fee of these but it wont go through. Thoughts? Thank you
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Are you billing pediatric vaccines or adult vaccines in your RHC clinic?
 
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