Pediatric Coding Alert

Immunizations, an essential and frequent aspect of pediatric care, are creating a coding crisis. The costs, hidden and direct, of giving shots are going up for pediatric practices, while reimbursements are going down. Many pediatric offices and clinics are finding that they are not even breaking even much less making money. Here are some tips for coding -- and for getting reimbursed promptly and fairly -- for the administration of immunizations and the vaccine itself:

Code for an office visit plus immunization. This is the most important tip. If youre giving an immunization, you need two codes. You should be coding for both the office visit and for the immunization, says Arnold Friedman, MD, chief of ambulatory pediatrics at Mt. Sinai Medical Center in Cleveland. Even if the managed care company wont pay you for both, its important to code accurately so you can document what you have done and eventually persuade them to reimburse you correctly and fairly. Use the lowest level of service for the office visit, and the appropriate immunization code.

For example, a new patient being seen by the pediatrician getting a DTaP immunization would be coded 99201 and 90700.

However, its more likely that you will be immunizing an established patient. For such a DTaP immunization, you would use CPT 99211 for the office visit and 90700 for the shot. The physicians presence, in this scenario, is not
required.

If your managed care company objects to your listing both codes it may help you persuade them to pay-up if you refer them to the AMA 98 CPT book. The introduction to the immunization codes states: Immunizations are usually given in conjunction with a medical service. When an immunization is the only service performed, a minimal service may be listed in addition to the injection.

Tip: You can try adding a 25 modifier to the office visit code. Ive seen insurance companies deny claims arbitrarily if there are two codes without a 25 modifier, says Thomas Kent, CMM, office manager for Esther Y. Johnson, MD, FAAP, Dunkirk, MD. It is not technically necessary, but adding a 25 modifier will often get this correct coding practice past the sloppy payor computer edits.

2. Read your capitated contracts carefully. Correct coding is especially important if youre working under capitation, says Friedman, who is also a coding trainer for the AAP. Dont assume that all capitated plans pay for the same thing -- they dont. Carefully read your contract before you sign it, and if it doesnt specifically include payment for the vaccine, [...]