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Old 05-18-2009, 01:46 PM
dballard2004 dballard2004 is offline
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Default Can someone please clarify 90472

Can someone please clarify for me the correct use of CPT 90472? Do my understanding, this code is to be used for each addtional vaccine. Does this mean that if a patient presents for three vaccines, we would code:

Vaccine 1-90471 (plus vaccine)

Vaccine 2-90472 (plus vaccine)

Vaccine 3-90472 (plus vaccine)

or

is it only coded once regardless of the number of vacicnes given? Thanks.
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Last edited by dballard2004; 05-19-2009 at 05:42 AM.
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Old 05-18-2009, 02:16 PM
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surgonc87 surgonc87 is offline
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That would be correct. They would also accept

90471
90472x2 with the DX for each additional code listed usually up to four.
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Old 05-18-2009, 02:23 PM
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mitchellde mitchellde is offline
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It should be listed as
90471
90472
90472 - 59
Many offices I work with are getting either underpaid or denied for units out of range when coding with units. The 1500 billing manual states units must be 1 unless it is a timed service or items that are distributed as quantity like drugs. when the codes states each additional vaccince then each vaccine given is unique and distinc from the other so listing it with a 59 is the better way to communicate what was done.
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Old 05-18-2009, 05:51 PM
dballard2004 dballard2004 is offline
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Interesting! Thanks to all that replied!
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Old 05-19-2009, 05:37 AM
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Although 90472 is defined as each additional vaccine, most payers will pay it only twice (three vaccines total) regardless of how many wre administered.
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Old 05-19-2009, 07:57 AM
Lisa Bledsoe Lisa Bledsoe is offline
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The correct coding would be:

90471
90472 x# (however many additional IM immunizations administered).

The definition of 90472 states "each additional...list separately in addition to code for primary procedure". We do not have issues with any of our payers for the additional administrations and often it is more than 3 additional.

You would not want to list each individually as they will deny as duplicate. You should not use mod -59 (or -51) with an add-on code.
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Old 05-19-2009, 08:24 AM
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I 100% agree with Lisa
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Old 05-19-2009, 09:07 AM
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Add on codes are 51 exempt not all modifier exempt, and therefore you can use the 59 on an add on code. Some payers will pay with units but some do not and even those that pay some do not pay the correct amount. It is still in the billing manual as units great than 1 not allowed with the except as those that come as a quantity and each is not a quantity, the instructions state list separately. Therefore tha correct way is with the 59 modifier. Some denials and underpayments come with the explanation of units out of range which is why a lot of folks say the payers will only pay for a certain number.
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Old 05-19-2009, 09:39 AM
Lisa Bledsoe Lisa Bledsoe is offline
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Quote:
Originally Posted by mitchellde View Post
Add on codes are 51 exempt not all modifier exempt, and therefore you can use the 59 on an add on code. Some payers will pay with units but some do not and even those that pay some do not pay the correct amount. It is still in the billing manual as units great than 1 not allowed with the except as those that come as a quantity and each is not a quantity, the instructions state list separately. Therefore tha correct way is with the 59 modifier. Some denials and underpayments come with the explanation of units out of range which is why a lot of folks say the payers will only pay for a certain number.
What billing manual would this be located in? My experience is as stated in my previous post and we have not had any issues to my knowledge with reduced reimbursement on 90472 billed as "units". If you have the same number of immunizations as the number of administrations reported there should not be a quantity issue and if there is I would appeal. I respectfully disagree with the use of mod -59 on 90472.
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Old 05-19-2009, 09:50 AM
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Lisa,
we may just have to disagree, the 1500 has its own billing manual that has been continuously updated thru the years. Many times you may have read the statement but it is subtle and many people miss it. However I discovered it when we continued to be under paid and or denied when this was done, I did a ton of research and finally deciphered the statement. They use the language of quantity distribution and then do not clarify what this is referring to. I am sorry that you disagree but I maintain the 59 modifier is correct regardless of which method you wish to use. I know several will continue to use units. So we will just have to let it go at that.
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