Pediatric Coding Alert

Some pediatricians are being so poorly reimbursed for RotaShield, the rotavirus (RV) vaccine (90680), that they are wondering whether they should offer it. And some, like Charles A. Scott, MD, FAAP, a regional CPT coding resource physician for the AAP, are not even ordering it. And, says Scott, that may be the best route of all for many.

Managed care companies in our area have decided they would pay just barely over our cost, says Scott, who practices at Medford Pediatric and Adolescent Medicine in Medford, NJ. Were not giving it for that kind of compensation. So Scotts practice is simply not stocking the rotavirus vaccine at all.

The American Academy of Pediatrics (AAP), in a statement issued last fall (see PCA, Dec. 1998, page 91), gave pediatricians support for decisions like Scotts. Based on safety and efficacy data, RV vaccine is recommended for use in infants at 2, 4, and 6 months of age for prevention of RV infection, the AAP said. Then, however, the statement added: Routine implementation of this recommendation will require reconciliation of related economic issues.

This was the first winter that the rotavirus vaccine was available. Was there less rotavirus than usual? No, according to the Scott. We had a tremendous outbreak of rotavirus in the past year, he says. But the good news is that the children who had to be hospitalized for rehydration were all older children mostly around two or three years old not the high-risk group of infants. And they were not even admitted, says Scott of these children who did need intravenous fluids. They stayed in the ER for 12 hours on an IV, he explains.

Another solution, for pediatricians who really believe in RotaShield, is to ask the parents to pay for the vaccine, says Scott. Tell the parents, We have a vaccine thats available, but your insurance company isnt being honorable about paying for it, he says. Tell parents to hold on to their receipt in case the insurance company decides in the future to allow payment for the vaccine. At that time, they can resubmit the claim to the carrier for reimbursement.

Non-covered vs. Non-allowed Service

What if the managed care company objects to this kind of activism on the part of the pediatrician? If managed care says this kind of talk is against the contract, I dont want to hear that, says Scott. Its also against the contract for them to pay us six months late or not to pay us enough.

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