How to Fight the Bundling of Immunization Codes
Published on Sat Jan 01, 2000
CPT Codes 2000 solved the vexing problem of 90472 (its no longer for administering two or more vaccines, but rather for each subsequent vaccine), making it much easier for pediatricians to be fairly reimbursed when they give four or five vaccines. But managed care companies are undercutting the whole purpose of 90471 (immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections and/or intranasal or oral administration]; 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]).
These commercial payers are saying the codes are bundled into the preventive-medicine services codes (99381-99397). Some insurance companies are claiming that you can use only the administration codes when there is no preventive-medicine services visit on the same day. This is how you know they are bundling the codes, even though this is not an official Medicare bundle. Rather, it is a maverick bundle adopted by some health plans that dont like the idea of paying for administration. And pediatricians, who give far more immunizations than any other physician group, are hard hit by this policy.
You dont have to accept it, says Curtis J. Udell, CPAR, president and CEO of Emphysys, a Cummings, Ga.-based firm that provides compliance services for physicians, including many pediatricians. But you do have to contact the payer and ask what theyre doing to offset your costs. This means that you need to make sure the money being taken out of the picture by not recognizing the administration codes is being put back in by adding more to every preventive-medicine services code. They should be adding another five or six dollars for the well visits, says Udell.
Richard H. Tuck, MD, FAAP, of Primecare Pediatrics in Zanesville, Ohio, and founding chair of the American Academy of Pediatrics committee on coding and reimbursement, agrees. In fact, Tuck took one health plan to task over this issue. I talked to the medical director and the quality assurance committee of Nationwide [the health plan], he says. I explained that this was against the emphasis being put on immunizations by the NCQA. (The NCQA accredits managed care plans, and employers look for this accreditation before selecting a plan, so following NCQA guidelines is given high priority by quality plans.) I explained that pediatricians will send children to the health department for immunizations if managed care plans wont cover the costs. Tuck is now waiting to hear from the plan on the results of his complaints.
The point is that you do have to say something to the plan. Emphasize that the new administration [...]
