Pediatric Coding Alert

Question:,/B> I billed a Varivax shot (90716) for $63, and the insurance company paid only $9. The cost of this vaccine is $42 a dose.

Ricardo J. Costa, MD
Rancho Cucamonga, Calif.

Answer: You have correctly coded for the immunization of Varivax using code 90716. Is this the only insurance company to reimburse so poorly, and have you checked with them to verify that they paid properly according to your contract? If you have questioned them and the response remained the same, then you should file an appeal documenting the cost of the vaccine and demonstrating other payers reimbursement rates. If this fails with this payer, then you may want to refuse to give this immunization to the patients who carry this insurance. Explain to them the problem, and enlist their assistance in appealing to the insurance company. Additionally, remember to use the vaccine administration codes (90471 for initial, 90472 for each subsequent) when giving any immunization.

Note: For more on the vaccine administration codes, see column Understanding the New Vaccine Administration Codes on page 36 this issue.