Pediatric Coding Alert

If you are having a hard time getting paid for 90471/90472, you have to fight for it, says Thomas A. Kent, CMM, president of Kent Medical Management in Dunkirk, Md. For example, the health plan might say immunization administration is included in the well visit, and therefore you shouldnt get paid for vaccine administration.

Kent recommends that you request a copy of the manual or contract showing this policy as a written statement and the date of implementation. The plan must also show documentation that demonstrates notice to the pediatrician of this violation of CPT principles, says Kent. Often these are strictly internal, oral policies which do not have the force of the contract behind them. The following are Kents main strategies for fighting this problem:

Send a letter requesting the above proof of policy implementation. Close with a paragraph stating that you are giving the plan 15 days to confirm this policy in writing. Failure to respond will indicate acceptance of the CPT standard and all submissions of 90471 and 90472 will be payable at the rate of $X.XX and $Y.YY respectively.

If the provider services representative cannot provide the requested documentation, take the issue to the medical director, urges Kent. Request immediate recognition of the administration codes including back payment, he says.

In getting providers to recognize modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service), photocopy the page in CPT which describes CPT 90471 /CPT 90472 , and which also, in the introduction to the section, says: If a significant separately identifiable evaluation and management service (e.g., office or other outpatient services, preventive medicine services) is performed, the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration codes.

Send this page in with your claim. Discuss it with the medical director if necessary. Its clear that the vaccine administration is not included in a preventive medicine services visit in terms of coding.