Pediatric Coding Alert

by Joel Bradley, MD, FAAP

This months columnist, Joel Bradley, MD, FAAP, is chief of staff-elect at Gateway Medical Center in Clarksville, Tenn., and a member of the American Academy of Pediatrics(AAP) Coding and Reimbursement Committee. He is also the editor of Coding for Pediatrics, published by the AAP and one of eight pediatricians in private practice with Premier Medical Group in Clarksville, Tenn.

Because the vaccine administration codes (90471-90472) are relatively new (many insurance companies dont start until April 1 with new CPT Codes for the current year), you should send a letter to your major payers stating how you intend to bill for the vaccines. Send a copy to the medical director; after all, that is the person who is in charge of clinical quality measures for a health plan, and immunization rates are important indicators for accreditation.

There are four key issues affecting vaccines that should be part of every contract negotiation for pediatricians, whether at the solo-provider or the large- group level.

1. The new codes. Managed care has challenged most physicians to react to change after change, and charging for vaccine services given in the office has certainly been no exception. Not long ago we used a global code to bill for vaccines that usually included both the cost of the product and some reimbursement for giving it.

Next came new codes for the administration onlyin 1999 code 90471 (immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections and/or intranasal or oral administration]; one vaccine [single or combination vaccine/toxoid]) for the first vaccine, and 90472 (each additional vaccine) for two or more vaccines. There were new codes too for each separate vaccine product, and in some cases for a different dose or age group. One then bills using both codes to capture the costs of the product and the expense of the administration. For CPT 2000 the second code (90472) was revised at the request of the AAP so that now it can be used for the second and each subsequent vaccine.

2. Relative value units. Coding is just one issue, as many providers who have checked their reimbursements and denials know. How should one value the administration codes, and what should we expect the payers to pay? All new and many revised codes go from the CPT process to the AMA for a recommended value by the RVS Update Committee (RUC). This was done with the vaccine administration codes, and a relative work value was recommended and forwarded to HCFA for inclusion in its Medicare fee schedule for the year 2000. When [...]