Pediatric Coding Alert

Question: Our physician billed 90634, 90710, and 90606 for vaccines given to a 5-year-old patient. The insurance company denied payment and said they required a modifier. What should we have done differently? New Hampshire Subscriber Answer: According to standard CPT coding, vaccine codes do not require modifiers on the associated E/M code. However, you might need to include modifier 25 (Significant, separately identifiable evaluation and  management service by the same physician on the same day of the procedure or other service) if your insurance company requires it -- which might be why you received a denial. Well check: If your physician administered vaccines on the same day as a well visit, code the well visit with the appropriate code such as 99393 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, [...]