Pediatric Coding Alert

Since the vaccine-administration codes (90471, immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections and/or intranasal or oral administation]; one vaccine [single or combination vaccine/toxoid], and +90472, ... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) were created in 2000, pediatricians have been fighting to get paid for them. Now that there are two new codes (90473, immunization administration by intranasal or oral route; one vaccine [single or combination vaccine/toxoid], and +90474, ... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]), this problem is sure to continue.
 
Insurers have used a variety of methods to deny payment, but in many cases ignorance of CPT rules, not payer greed, is the culprit.
 
Recently, a Blue Cross/Blue Shield (BC/BS) carrier apologized for its policy of requiring modifier -51 (multiple procedures) with CPT 90472 . Modifier -51 generally reduces a procedures fee by 50 percent.
 
Because 90472 is an add-on code, no modifier is required. However, BC/BS required providers to append modifier -51 if the code was used more than once on a date of service. This resulted in decreased payments for pediatricians who perform often multiple immunizations.
 
The American Academy of Pediatrics (AAP) contacted the carrier, CareFirst, which insures more than 3 million people in Maryland, Delaware and the District of Columbia, about the error. To its credit, CareFirst apologized and published a correction in its September bulletin, noting that modifier -51 is not required for 90472.