Pediatric Coding Alert

Question: How can I tell if Medicaid will pay for vaccine administration codes?

Michigan Subscriber  
Answer: You might think Medicaid would be standardized, because its a government-run program. But most of the money comes from the states, so each state has the option to write its own rules. In some states, Medicaid carriers follow the lead of some of the private payers and will not pay for vaccine administration codes (90471-90474).
 
In some states, Medicaid carriers have outdated coding policies; for example, the carriers may tell you to file 99211 (established patient office or other outpatient visit, that may not require the presence of a physician) for vaccine administration. If they do, you need to ascertain exactly how they want you to file the claim. Code 99211 should not be used if the patient is well. Also, if you bill a preventive medicine services code (99391-99395), you cannot bill another E/M code, such as 99211, in addition. However, if that is what Medicaid tells you to code, you have no choice its the only way to get paid, and the payer ultimately sets its coding policy.
 
Some states require you to use the HCPCS Level III codes, which are state-specific alphanumeric codes, for vaccine administration.
 
Remember also that the state supplies free vaccines for Medicaid patients and, in some states, free vaccines for all patients. Code the appropriate CPT code for the vaccine, but put a zero charge for it. Then, use the state-required code (9047x, 99211, or HCPCS code) for reimbursement for administration.
 
States set the limits on what you can bill Medicaid for administration. Some states pay better than others. The range is from less than $1 to more than $17.
 
Many pediatricians, in some states, no longer give immunizations. Instead, they send their patients to the government health department to administer them. This represents an unfortunate fragmentation of care.
 
Tip: If your state has payment rules that vary from standard measures, ask for them in writing. The person you are talking to on the phone may not know the rules. You can also contact your local community health service for information about proper billing.